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GoMococci IN Pus. 
stained by — 1, Knaack's method. 2, N'eisser's double stain. 3, Lanz's method. 
4, Loffler'a methylene-blue. 5. Romanowsky'.s stain (Leishman'a modi6cation). 6, Leszczyn- 
sky's method. 


















Copyright, 1913, by W. B. Saunders Company 



3iol)n <3. Clarfe 


In this exceedingly comprehensive volume on gonorrhea Dr. 
Norris has placed before us, in a most interesting and instructive way, 
the many phases of this subject. The historic narrative, which leads 
back to the earliest records of the disease, is intensely entertaining, 
following as it does the curious and bizarre views expressed in ancient 
literature regarding the affection up to the description of the remark- 
able experiment performed by Hunter upon himself, in which he en- 
deavored to show that the specific virus of gonorrhea and that of 
syphilis were interchangeable. As a result of this remarkable but 
fallacious experiment Hunter's theory of the mutual identity of the 
two infections was accepted by the profession without further question. 
In spite of the later and well-sustained dissent by Ricord, this view con- 
tinued to hold sway, and was not entirely dissipated until the dis- 
covery, by Neisser, of the specific microorganism of gonorrhea. This 
discovery put an end to the long-agitated discussion, and for the 
first time a scientific foundation was established upon which all mod- 
ern work along this line has been constructed. 

One learns from the ancient documents, as set down by Dr. Norris, 
that the ravages of gonorrhea were recognized, and that strenuous 
efforts were made, by segregation and other restrictive means, to 
limit its spread. 

In the chapter on Bacteriology and the Pathogenesis of Gonorrhea, 
the author has very clearly described the best cultural and staining 
methods, and traced the destructive efTects of the gonococcus upon the 
pelvic organs and other tissues of the body. This study is elaborately 
illustrated from gross and microscopic sections made by Dr. Norris 
from the extensive collection in the pathologic laboratory of the Gyne- 
cologic Department of the University of Pennsylvania. The litera- 
ture has been carefully compiled, and has been so well digested as to 
furnish an almost encyclopedic review of all the various aspects and 
history of the Neisserian infection. 

In the chapter on Sociology the author has considered the relation- 
ship of gonorrhea to sterility and abortion, and has shown the havoc 
that is wrought in the destruction of the eye-sight of new-born infants 
as the result of maternal infection. Statistics have been carefully 
compiled demonstrating the serious efTects of this disease upon the 


given individual, and, more especially, its pernicious influence upon 
the general civic body. 

The various methods adopted by the governments of Europe and 
the Orient for the limitation and suppression of the social evil have 
been reviewed, and the situation as it exists in the United States has 
been very thoroughly dealt with. Arguments for and against muni- 
cipal supervision of prostitution are presented, and the author accepts 
the conclusion, reached by the majority of physicians and a large body 
of social workers, that legal restraint is of little actual value in the 
curtailment or abrogation of this evil. 

Under the head of Prophylaxis the methods of preventing the spread 
of the disease are presented. Special stress is laid upon the necessity 
for educating patients as to the communicability of this malady, and 
for protecting innocent individuals against its serious immediate and 
remote effects. The author insists upon the necessity for an obliga- 
tory certificate of health for the male before marriage should be per- 
mitted. He condemns the policy of rigid secrecy relative to venereal 
diseases that now prevails, and lays particular stress upon the ad- 
vantage to be gained by making these diseases notifiable. In other 
words, the author would have gonorrhea treated like all other dis- 
eases that, through their contagiousness, threaten the general public. 
Individuals so affected should, therefore, he maintains, be segregated 
in special hospitals or kept under rigid observation until a cure has 
been effected. 

A full description of the approved methods of examination and of 
the means for ascertaining with certainty the presence of the gono- 
coccus is given in a separate chapter. The necessity for ascertaining 
when a cure has been efTected has been dwelt upon. The author 
deplores the light and careless manner in which gonorrhea has been 
treated in the past, and considers the profession partially responsible 
for the spread of this disease. He regards as criminal laxity the 
neglect of physicians to determine that an actual cure has been effected 
before an infected individual is permitted to marry. 

In tracing the pathologic changes incident to this infection, a 
topographic sequence has been adopted, beginning first with the ex- 
ternal genitalia and following the process through the generative tract 
to the ovaries and tubes. 

A subsequent chapter is devoted to a comprehensive description of 
operative methods of treatment, and special attention is directed to 
the necessity for instituting conservative medical treatment before 
surgical intervention is undertaken. Thus the surgeon endeavors to 
subdue the inflammation, and later, if necessity arises, removes, by 


surgical means, anj' pathologic residuum or debris that may remain 
after the gonococcal storm has passed, conserving those organs or 
portions of tissue that still have functional value, rather than sacri- 
ficing the pelvic generative organs in toto. This conservative policy 
should be applied particularly to young individuals, in whom this 
infection so frequently occurs. 

A chapter has been devoted to the consideration of Diffuse Gon- 
orrheal Peritonitis, a subject that is comparatively little understood 
by physicians and surgeons, because of its infrecjuent occurrence, the 
infection usualh' expending its virulence upon the adnexa and the pelvic 
peritoneum and rarely spreading to the upper abdomen. 

An important chapter is that dealing with Gonorrhea During Preg- 
nane}', Parturition, and the Puerperium. In maternity cases it is 
especialh' important for pM-.sicians and attendants to be ever on the 
alert, first, to prevent the spread of the disease in the mother, and, 
secondly, to give the most minute attention to the new-born child, to 
protect it against the life-long misery that may come from ophthalmia 

The final chapter deals exhaustively with the medicinal treatment 
f)f gonorrhea. The various clinical methods for the detection of the 
infection and a comparative study of the results of treatment are 
given in comprehensive detail,- with a final summarj', bj' the author, 
of what he considers to be the proper therapeutic care of these patients. 
The relative value and the present status of the serum and vaccine 
treatments are considered in this chapter. An extensive bibliography, 
from which the author has selected a vast amount of splendid material, 
citing innumerable articles to which one may turn to consult these 
original sources, completes the book. 

The careful student will find, after a close perusal of the work, that 
the author has written a highly instructive treatise, in which he has 
most satisfactorily encompassed the many aspects of this complicated 
cjuestion. He has reviewed in detail the several divergent sociologic 
\iows concerning this collosal evil, and, as a commentary, offers 
,iu<licious suggestions that will be of value to those who are endeavoring 
to find the best solution for these problems. Because of the broad and 
comprehensive character of the I)ook, it will be of great value to the 
physician, tlic surgeon, the specialist, the legishitor, and tiic sociologist. 

John Ci. C'l.\kk. 


Until a comparatively recent date gonorrhea has been regarded 
by many medical men as a purely local disease, and it is only during 
the last twelve or fifteen years that the rare lesions resulting from this 
infection have been traced to their proper source. Indeed, prior to 
the appearance of Noeggerath's epoch-making monograph even the 
common intraperitoneal manifestations of gonorrhea were not recog- 
nized. Up to this time practically all pelvic inflammations were re- 
garded as cellulitis, and their etiologic relationship to gonorrhea was 
not generally known, although Goupil and Bernutz had described 
the pathology as early as 1862. The discovery of the gonococcus by 
Neisser in 1879 placed the study of gonorrhea upon a scientific 
basis, and within recent years the symptomatology and pathology 
that follow in the wake of this infection have received marked 

In the preparation of a work such as this one of the chief difficulties 
consists in selecting the important and omitting the unimportant 
references to the ^'arious subjects dealt with. This difficulty will be 
apparent when it is considered that during the last ten years over 
20,000 papers bearing more or less directly upon the subject of gon- 
orrhea have appeared. From this voluminous material over 2300 
references have been utilized, and even in this moderately extensive 
list it is likely that some important publications have been over- 
looked. The chapter on Serum and Vaccine Therapy and Organo- 
therapy is based largely on the work of other investigators. For the 
indications and technicof this form of treatment the reader is referred 
to the special chapter devoted to this subject. Chapters XI and XII, 
the substance of which appeared in Surgery, Gynecology, and Obstet- 
rics, October, 1910, and which was written in collaboration with Dr. 
John G. Clark, have l^een extensively revised and brought up to date. 

In the selection of the literature an endeavor has been made to 
utilize only such material as embodies the most modern trend of science 
or that refers to rare cases. The attempt has been made to incorporate 
either references to or abstracts from the reported histories of all 
unusual gonorrheal lesions. Thus, under this head will be found a 
short abstract of all cases of rupture or torsion of the uterine adnexa in 
inflannnatory conditions, of all gonorrheal lesions of (he i)l('ura and 


kidney, etc. The not infrequent practice of reporting rare cases 
under misleading or ambiguous titles is especially to be deprecated, 
and makes the complete list of such cases practically impossible to 

I wish to acknowledge my indebtedness to the excellent papers of 
Finger and Spooner, which have been extensively drawn ujion in com- 
piling the chapter on the History of Gonorrhea. Stephenson's mas- 
terly monograph on ophthalmia neonatorum has been freely utilized 
in the chapter on eye lesions. Nixon's important article on renal 
gonorrhea, and Menge's monograph on gonorrhea in women, have also 
been found of great assistance, as well as many other valuable contribu- 
tions too numerous to mention, the references to which can be found 
in the foot-notes. 

In the preparation of this work I have received the most hearty 
support and encouragement from Dr. John G. Clark, who has placed 
at my disposal his abundant clinical and pathologic material. It 
gives me much pleasure to acknowledge my indebtedness to Dr. 
Thomas B. Hollo way, who has kindly reviewed the chapter dealing 
with eye lesions and has made many valuable suggestions. My thanks 
are also due to Dr. George W. Outerbridge for reading the chapter 
on the Patholog.y of the Female Genital Tract, to Miss Dorothy 
Peters, for the excellent illustrations, and to the W. B. Saunders Com- 
pany, for much practical aid and for painstaking efforts to obtain 
the best possible reproductions of the drawings. 

Charles C. Norris. 

1.503 Locust Street, Philadelphl\, Pa., May, 1913. 



Historic 17 

Bacteriology of the Goxococcrs 44 


Pathologic Changes Produced by the Gonococcus in the Fe\l\le Genital Tract 87 

Vulvitis 89 

Inflammatory Lesions of Bartholin's Gland 89 

Condylomata Acuminata 93 

Vaginitis 93 

Urethritis 95 

Cervicitis 96 

Corporeal Endometritis and Metritis . .' 98 

Salpingitis 105 

Oophoritis -. 114 


Pathogenesis 117 

Sociology 126 


I'kostitution 149 

Prophylaxis — -Method of Dealing with G()N(jrrheics to Prevent the Spread op 

THE Disease 164 

'I'mk Examination of 1'atients 183 

('IIAI'T1;K 1.\ 

Gonorrhea of the External IIenitalia 195 

Vulvitis 195 

Condylomata Acuminata 198 

Bartholinitis 201 

Cyst of Bartholin's Gland 203 

Abscess of Bartholin's C !land 204 

Urethritis "205 




Gonorrheal Vaginitis and Cervicitis 213 

Vaginitis 213 

Vaginal Condylomata 222 

Cer\'icitis 222 

Pruritus Vulva> 230 

Condylomata of the Cervix 231 


Gonorrheal Endometritis, Metritis, and Intramural Uterine Abscess 232 

Endometritis 232 

Acute Endometritis 234 

Chronic Endometritis 237 

Adenomyoma of the Uterus with Chronic Endometritis 245 

Metritis 246 

Acute Metritis 246 

Chronic Metritis 248 

Intramural Abscess of the Uterus 252 


Gonorrhea of the Fallopian Tubes and Ovaries 259 

Acute Pelvic Inflammatory Disease 263 

Clu'onic Pelvic Inflammatory Disease 265 


The Treatment of Pelvic Inflammatory Disease 274 

The Time to Operate on Cases of Pelvic Peritonitis 284 

Conservative Surgery of the Uterus and Appendages in Cases of Gonococcal Pelvic 

Peritonitis 285 

Conservative Surgery of the Fallopian Tubes 285 

Conservative Ovarita Surgery 287 

Salpingectomy. Ovarian Conservation and Suspension of the Uterus 290 

Ovarian Conservation after Hysterectomy 299 

Conservative Uterine Surgery 300 

The Condition of the Vermiform Appendix in Cases of Pelvic Peritonitis 301 

Immediate Mortality of Conservative Surgery 302 

End-Results of Conservative Surgery 303 

Pregnancies Resulting after Conservative Surgery 305 

Possibilities of Ectopic Pregnancy Following Conservative Operations 307 

Proportion of Cases Requiring a Secondary Operation after a Conservative Opera- 
tion 307 

Conclusions 308 

Hysterectomy and Bilateral Salpingo-oophorectomy for Pelvic Inflammatory 

Disease 311 

Drainage in Cases of Pelvic Inflammatory Disease 314 

Corpus Luteum Organotherapy for the Artificial Menopause 316 

Post-operative Care of Cases of Pelvic Inflammatory Disease 318 

Unusual Manifestations and Remote Complications op Pelvic Inflammatory 

Disease 319 

Rupture of Inflammatory Uterine Adnexa into the Peritoneal Cavity 319 

Torsion of Inflamed Uterine Adnexa 339 


Diffuse Peritonitis 355 

Hydrops Tubse Profluens 360 

Infection of Intrapelvie Neoplasms 361 

Mixed Infection 362 

Gonorrhea as the Etiologic Factor in the Causation of Ectopic Pregnancy 363 

Gonorrhea as a Predisposing Factor to Carcinoma 363 

Herniated Inflammatory Adnexa 364 

Esthiomene and Elephantiasis 364 


Gonorrhea in Pregnancy, Labor. ant> the Puerperium 366 

Puerperal Infection 368 


Gonorrhea in the Extremes of Life 376 

Gonorrhea in Children 376 

Gonorrhea in the Aged 387 


Complications ant) NoN-GE^^TAL Gonorrhea. — Cystitis. — Adenitis. — Proctitis. 
— Stomatitis. — Rhinitis. — Ophthalmia in Infants, Young Girl.s, antj 

j\j>nLTS • 390 

Cystitis 390 

Lymphadenitis 394 

Proctitis , 395 

Stomatitis 398 

Rhinitis 401 

Ophthalmia Neonatorum 402 

Conjunctivitis in the Adult 413 

Gonorrheal Septicemia, Bacteremia, and Toxemia. — Gonorrhea of the Osseous 


Septicemia, Bacteremia, and Toxemia 418 

Bone and Joint Lesions Produced by Gonorrhea 425 

Tenosynovitis 433 

Osteoperiostitis 433 

Perichondritis and Chondritis 435 

Cardiac Lesions 436 

Endocarditis 436 

Pericarditis 438 

Myocarditis 439 

Aortitis 439 

Phlebitis 439 

Thrombosis 441 

Gonorrheal Skin Lesions. — Gonorrhea of the Lungs, Pleura, Kidneys, and 
Nervous System. — Parotiditis. — Otitis. — Suppurative Myositis and 

Subcutaneous Abscess. — Wound Infection 442 

Skin Lesions 442 

Gonorrhea of the Lungs 449 



Pleurisy 450 

Gonorrhea of the Kidney 452 

Perinephritis 461 

Gonorrhea of tlie Nervous System 461 

Parotiditis 465 

Otitis 465 

Suppurative Myositis and Subcutaneous Abscess of Gonorrheal Origin 465 

Wound Infection 467 


Gonorrheal Therapy 469 

Drugs Employed in the Local Treatment of Gonorrhea 469 

Serum and Vaccine Therapy for Gonorrhea 486 

Vaccines 493 

Index of Names 497 

Index 511 



1. Method of Reduplipution of the Gonococci 45 

2. EiKlocervicitis ....'. facing 96 

3. Endometrium During the Postmenstrual Period facing 98 

4. Endometrium During the Interval facing 98 

5. Endometrium During the Premenstrual Stage facing 99 

6. The Decidua of Intra-uterine Pregnancy facing 100 

7. Glandular Epithelium During the Postmenstrual Stage facing 101 

8. Glandular Epithelium During the Interval facing 101 

9. Glandular Epithelium During the Late Premenstrual Stage facing 101 

10. Typical Opitz-Gebhard Glands, Showing Fern-like Ingrowths of Proliferating Epi- 

thehum facing 102 

1 1 . Stroma Cells facing 102 

12. Hypertrophy of the Cervix, Chronic Endometritis, Chronic Metritis, and Bilateral 

Adnexitis facing 104 

13. Endometritis and Metritis facing 104 

14. Uterus and Adnexa from a Case of Pelvic Inflammatory Disease facing 106 

1.5. Uterus and Appendages from a Case of Advanced Pelvic Inflammatory Disease, 

with Bilateral Tubo-ovarian Abscess facing 10^ 

10. Acute Gonorrheal Salpingitis '.-. facing 108 

17. f lonorrheal Salpingitis ! facing 109 

18. Unusually Large Pyosalpinx facing 110 

19. Section Through an Advanced Chronic Pyosalpinx facing 111 

20. Section Through a Pyosalpinx , facing 112 

21. Hydrcsalpinx facing 113 

22. Cross-section Through an Ovarian Abscess of Lutein Origin facing 114 

23. Pyosalpinx and Ovarian .\bscess facing 115 

24. Tubo-ovarian facing 115 

25. Uterus and Appendages from a Case of Advanced Pelvic Inflammatory Disease 

facing 116 
20. Tubo-ovarian .Vhsce-ss faring 1 17 

27. .\gc Distribution of Death from \'enereal Disease, Per Cent. (Brown, H. .\.: New 

York Med. Jour., June 17, 1911, p. llS.'j) 126 

28. Condylomata Acuminata of the External Genitalia facing 198 

29. Diagram of the Blood-supply of the Fallopian Tube. . .' 291 

30. Photograph Showing the Arterial Blood-supply of the Normal Tube, Ovary, and 

Uterus facing 292 

31. Bilateral Salpingectomy, Ovarian Conservation, and Suspension of the Ovary and 

Uterus. First Step facing 293 

32. Richar<lson'a Single ia) and Double (6) Figure-of-S Suture (Richardson, E. H.: 

Jour. Amer. Med. A.s.soc., May 7, 1910 294 

33. Bilateral Salpingectomy, Ovarian Conservation, anil Suspension of the Ovary and 

Uterus. Second Step facing 294 

34. Bilateral Salpingectomy, Ovarian Conservation, and Suspension of the Ovary and 

Uterus. Tliird Step facing 294 

35. Acute Purulent Salpingitis facing 340 

36. Carcinoma Which Occurred in ihi' Fallopian Tube of a Young Woman facing 304 




37. Carcinoma of the Fallopian Tube (Higli and Low Power) facing 364 

38. Keratodermie Blennorrhagique facing 446 

39. Gonorrheal Keratosis facing 448 

40. Keratodermie Blennorrhagique . . facing 448 


Plate L Gonococci in Pus ' Frontispiece 

Plate IL Urethritis and Bartholinitis facing 208 

Plate IIL Acute Gonorrheal Cervicitis and Urethritis facing 224 



The term gonorrhea originated with Galen/ who described the con- 
dition about A. D. 1(50. He believed gonorrhea to be an involuntary 
escape of semen. The word itself is derived from the Greek yovi), 
seed; and ptlv, flow. Blennorrhea is a flow of mucus; blennorrhagia, 
an outpouring of mucus; whereas pyorrhea indicates a purulent dis- 
charge. It will be seen that, therefore, etymologically, the term '" gon- 
orrhea" is inaccurate. The name has, however, been so generally 
adopted, and is in such common usage, that any change of title of this 
disease would be ill advised and lead only to confusion. "Clap," a 
term so often applied to gonorrhea, especially in men, is, according to 
Sevediaur, derived from "clapiers," which were public shops kept by 
prostitutes. Lacroix,- however, tells us that in Paris, during the Middle 
Ages, the prostitutes were domiciled in a quarter ultimately designated 
Clapier, and that it is from this locaUty that the word derives its origin. 
The terms — clap and gonorrhea — are used interchangeably by many 
writers. Among the synonyms of gonorrhea known to the laity are 
such terms as drop, nipper, a dose, and other more vulgar names. 
Although there are no means at our command of positively identifying 
gonorrhea in the early ages, it is almost certain that the disease can be 
traced back to the earliest records of the liuman race, its progress 
through the generations having left in its wake a blind, halt, maimed, 
sterile, and sexless multitude. Proksch'' reports that an old Japanese 
manuscript, written in b. c. 900, contains an accurate description of 
gonorrhea. The disease was probably prevalent among the early 

Herodotus (b. c. 484) relates how, after the Scythians, during an 
expedition to .\scalon, a city of Hyria, had despoiled the temple of 

' Galen: Dc; Loi:. AITuc, 2, S, Edil. Uulin, 3, p. i)l. 

* Prostitution au Moyen Ago, Fol. ii; cf. Du Cangc, Glossar., sub. v, Clapier. 

' Prok.sch, J. K. : Die Gcschichte d. ven. Krankh., Bonn, P. Hanstoin, 1895, vol. i, p. 97. 

'Vi'it; Ilandb. il. Gyiiiikologie, vol. ii. 

2 17 


Venus Urana, they were attacked by a disease called "thenousos 
thelia." This was in all probability gonorrhea. Hippocrates men- 
tions dijsuria, and speaks of a whitish leukorrhea. Ureteral and pre- 
putial ulcers are described by Celsus (a.d. 164), who also refers to a 
purulent or bloody discharge issuing from the canal and orchitis, but 
does not mention that this was due to or followed sexual congress. 
His treatment consisted of cold baths, massage, with the local applica- 
tion of rue and vinegar, and food and drinks of a cooling nature. 
Galen (a. d. 130) believed that gonorrhea was due to the semen hav- 
ing acquired a poisonous quaUty. A similar view was held by Pliny 
(a. d. 115). Marcellus Empiricus, physician to the Emperor 
Theodosius, gives his treatment for what was probably gonorrhea. 
AU Abbas writes of the symptoms of urethritis, and recommends 
various refrigerant and sedative remedies, such as coriander, lentils, 
fleawort, poppies, roses, henbane, and lettuce, together with emetics 
and blood-letting, if the patient be of a plethoric habit. He also ad- 
vises sleeping in a cool bed and the wearing of a metal plate over the 
loins. Dioscorides' recommends the internal use of hemlock. Maim- 
onides describes urethritis as follows : ' ' The fluid escapes without erec- 
tion and without a feeling of pleasiii-e; the appearance of the discharge 
is similar to that of barley dough dissolved in water or coagulated al- 
bumin, and is the result of an internal disease; it is essentially differ- 
ent from the seminal fluid and mucus, the latter being more homogene- 
ous." The same writer mentions a number of causes for the disease, 
including amorousness and excesses of various kinds. Other references 
to venereal diseases, probably gonococcal in origin, may be found in 
the works of Juvenal, Martial, Sextus Placidus, Scribonius, and Are- 
t£eus. Although we have no indisputable record that gonorrhea ex- 
isted among the Romans, it seems practically certain that this was the 
case. Rome was the richest city in the world — a city whose inhabi- 
tants numbered four milUons (Lipsius) ; an era of peace, luxury, and 
vice hitherto unknown in the world's history had settled over the 
community. Prostitution was rife. Even Agrippina would leave 
the palace of the Caesars to spend the night in the brothels of the city. 
CaUgula had a brothel in his palace.^ Nero was a habitual frequenter 
of houses of prostitution, and dined in public at the great circus with 
hordes of prostitutes. The pubhc baths, which were used by men and 
women, boys and girls, all in a state of complete nudity, were little 
more than houses of assignation.^ According to Herodotus, the women 
threw aside their modesty with their clothes. The aliptes, or sham- 

' Dioscorides: Meth. med., vol. iv, p. 79. 

-Juvenal: Sat., vi. Pliny: Nat. hist., 33, 54. 


pooers, who massaged the bathers, were members of the lowest class. 
The most virtuous private citizens decorated the walls of their houses 
with lewd sculptures and lascivious frescoes.' The character of the 
Roman banquets is too well known to need description.^ Statues of 
Venus and of the god Priapus were exhibited freely to the public gaze. 
Offerings were made to these deities in the form of small cakes repre- 
senting the female and male organs of generation, and were sold in all 
the bakeries. The monstrous indecency of the statues of Priapus was 
their chief feature — an image that 

" Maids peer at through fingers hekl before the face." ^ 

The law regarded all servants waiting upon travelers at inns or 
taverns as prostitutes. Among all classes immorality reigned supreme. 
Well might Juvenal cry, "Vice has culminated!"^ Amid such de- 
praved conditions venereal disease must surely have thrived apace. 
In spite of this, these diseases occupy but a small space in the medical 
hterature of this period. This is due to two facts: first, the Roman 
physicians did not generally allude to these diseases, believing that 
they were beneath their dignitj'. Thus Celsus, before referring to the 
subject, apologizes for mentioning* the disease — "Quse invitissimus 
quigue alteri ostendit";^ and, secondly, the Roman phj'sicians re- 
fused to treat venereal diseases, which we find referred to under the 
general term "morbus indecens." As a consequence, the rich were 
treated by their slave doctors, whereas the poor were probably at- 
tended by the archiatri. who occupied somewhat the same position 
as docs the district physician of the present day, and who were bound 
to treat all diseases among the poor gratuitously, although they might 
demand a fee from the wealthy." 

For diseases of the groin the Romans used a plant called "bu- 
boniuin," from which the term "bubo" d()ul)tless took its origin. 
To the (ireeks this remedy was known as honboniinn. Roman women 
affected with secret were called aucunnuenUr, a term that 
explains itself. The Romans said of a female who communicated a 
disease to a man, "Haec to imbubinat" (Scalinger). Sanger" states 
that no pas.sage in the ancient writers directly ascribes venereal dis- 
eases to commerce with prostitutes, but adds, however, that no medical 

' Propcrtiu.s: ii, 0; Suet.: Tib. luul Vil. Ilor.; I'liiiy: xxxv, ;}?; sec also llir ccillic- 
tioMS at I he Mu.seo B()rl)oni(.'c at Naples, etc. 

' IVtrori: Satyr, vol. ii, pp. tiS, "0. " Martial; vol. iii, p. (iO. 

'Juvenal: Sat. vi. ' "What all men unwillingly show." — (Trans.) 

" Dig. 27, i, (i; Cod. Theoiios., xiii, .'5. I)e .\Ie(lic. el profess. 

• S.iMii.r. \V. W.: The History of I'rostitutioii, Th.' .Me.lical I'uhlishii.n'/ 'o., N'lAV York. 
HMHl. p. N.-) 


reader of the history of Rome under the Empire can doubt but the 
archiatri filled no sinecure, and that a large proportion of the diseases 
they treated were directly traceable to prostitution. 

The morality of the Greeks was no better than that of the Romans, 
and it is probable that venereal diseases were by no means unknown. 
Indeed, Dufour^ states that it was the fear of venereal diseases that 
was responsible for many of the sexual perversions of the ancient 

That the ancient Jews were acquainted with gonorrhea and were 
aware of its contagiousness there can be little doubt. In the fifteenth 
chapter of Leviticus, Moses, about B.C. 1471, not only warned the 
children of Israel of the dangers of gonorrhea, but laid down definite 
sanitary and pohce regulations for its prophylaxis, many of which might 
be adopted with advantage at the present day. In Deuteronomy, 
chapter xxiv, verse 1, it is stated that if a man marry a woman 
"and it come to pass that she find no favour in his eyes, because he 
hath found some uncleanness in her; then let him write her a bill of 
divorcement." The historian Josephus relates how the Jews, on 
their way to Canaan, contracted venereal diseases. In the Jerusalem 
Talmud numerous references are made to gonorrhea, and in the Baby- 
lonian Talmud venereal diseases are frequently mentioned. After a 
careful study of both Talmuds there can be little doubt in the reader's 
mind that gonorrhea played an important role in the etiology of the 
diseases of women in ancient times. In Numbers v : ii we find the 
Israelites instructed to "put out of the camp every leper, and every 
one that hath an issue." It should be stated that some difference of 
opinion has existed in regard to the interpretation of the word "issue." 
Some authorities believe that this does not refer to a venereal disease, 
and base their argument on the thirteenth verse of the fifteenth chap- 
ter of Leviticus, which says : ' ' \^^ien he that hath an issue is cleansed 
of his issue ; then he shall number to himself seven days for his cleans- 
ing." It is urged that if the word "issue" referred to a venereal dis- 
ease, the patient could hardly expect to be cured in eight days. This 
interpretation, however, appears incorrect, for if we consider the 
twenty-eighth verse of the same book and chapter, which deals with 
menstruation, we find, "But if she be cleansed of her issue, then she 
shall number to herself seven days and after that she shall be clean." 
From this it would appear that the proper interpretation of verse 13 
should be that "when he hath an issue and is cleansed of his issue 
(after being quite cured), he shall then number to himself seven daj^s 
for his cleansing." 

' Dufour: History of Prostitution. 


In the writings of the IMiddle Ages many references to gonorrhea 
occur. Among works of the early Arabian writers there are numerous 
and accurate descriptions of the symptoms and methods of treatment. 
Accurate dates of the various writings of this period are obtained with 
difficulty, but Johannes Mesue writes in the tenth or eleventh century 
as follows: "Si vero in via et ductus uriuEe ulcera sunt, cognoscuntur 
ex dolorc majis in urinse egrissione et sanie egrediente ante urinam. 
Ulcera virga? et apostemata sunt proportionalia ulceribus et apostema- 
libus testium."^ Ebu Sina describes urethritis thus: "Sentitur acuitus 
et mordicatio in egressione et quandoque est cum eo ardor urinse, et 
est color ejus ad citrinitatem declinis.'"- Serapion gives a clear de- 
scription of the suppurations of the external genitaha of women, which 
he believed were due to sexual excesses. He also writes at length of 
urethritis in the male, and recommends the use of hemp in its treat- 
ment. Rhanges describes a disease that caused burning during mic- 
turition. In the eleventh century Albucasis' treated urethritis by 
injections of vinegar and water. It is interesting to note that most of 
the earlier writers gave but little attention to gonorrhea in the female, 
the intraperitoneal complications of which were not recognized. 
Michael Scotus,^ physician to Emperor Frederick I, in the early part 
of the thirteenth century, recognized the infectious character of gon- 
orrhea. CJariopontus also discusses the disease. Lenfrancus, a dis- 
tinguished physician of the thirteenth century, who received his early 
surgical training in Paris in 1295-1306, and who was a pupil of William 
de Saliceto, describes the induration of the testicles. He also recog- 
nized the infectious nature of gonorrhea, and as a prophylactic recom- 
mended washing the penis in vinegar and water after coitus. Guido 
de Cauliaco, in his "Surgery," mentions urethritis as a condition fol- 
lowing intercourse with a diseased woman. Constantinus Africanus 
recommends remedies for strangury. Johannes de Gaddesden wrote of 
vaginitis, urethritis, and epididymitis. Johannes Ardern, physician to 
Richard II and Henry IV, believed urethritis to be due to excoriation 
of the urethra, and recommends as treatment injections of human milk, 
to which were added almond milk, sugar, and violet oil. Antonio 
Cermisone, a professor in Pavia and in Padua, and who died in the 
latter place in 1441, recognized gonorrhea as an infectious disease and 

' "The prcst'iicp of ulfors on tho urethra may be rpcognizod by the occurrence of seveie 
pain on urination ami tlic ilischarKc of purulent secretion and .shreds of tissue. The ulcers 
correspond with those on the penis and on tlie testes." — (Trans.) 

' "Sharp pain and itching are experienced during urination, and burning and smarting 
are present along the entire urethral canal. The urine is of a light lemon-yellow color." — 

' .\lbucasis: Lil). theoret. nee. non pract. .\l.sahar. .\ngus Windel. l.")l(l, fol.. p. !)2a. 

' Scotus: De Procr. et horn. Physion., op. S. 1, 1477, ('ap. O-IO. 


treated it by means of astringents. Further references to gonorrhea 
may be found in the works of Joannes Arculanus, Valescus de Taranta, 
Magninus, Guhehnus Vareguana, Antonio Cermisone, Johannes de 
Tornamira, and many others. Beckett tells us of an ordinance formu- 
lated by the Bishop of Winchester for the purpose of checking the 
spread of gonorrhea. One of the articles, "De his qui custodiant mu- 
lieres habentes nefandam infirmatatem," reads as follows: "That no 
Stewholder keep noo woman wythin liis hous, that hath any sycknesse 
of Brenning" (the perilous infirmity of burning). This ordinance is 
said to date back to the year 1162. Another ordinance of this Bishop 
is to the effect that no woman affected with ' ' the perilous infirmity of 
burning" shall be harbored in any of the eighteen houses of prostitu- 
tion that were situated in Southwark, and were said to have been under 
his jurisdiction. A somewhat similar ordinance was found, dated 
August 8, 1343, and attributed to Joanna I, Queen of both Sicilies, the 
fourth article of which was as follows: "The Queen commands that 
the Superintendent and a surgeon, appointed by the authorities, ex- 
amine, every Saturday, all the whores in the houses of prostitution. 
And if one is found who has contracted a disease from coitus, she shall 
be separated from the rest and live apart, in order that she may not 
distribute her favors and may thus be prevented from conveying dis- 
ease to the young men." The fear of venereal diseases in the early 
ages was very 'great. Sanger^ informs us that afflicted individuals 
were driven into the fields to die, the physicians refusing to attend the 
sick for fear of becoming infected. He also adds that many writers 
doubted this form of contagious influence, and held that it required 
intercourse, or at least contact. But nobles, and especially the clergy, 
preferred to ascribe their maladies to misfortune rather than to licen- 
tiousness, and sought to "put down" such innovations. The conse- 
quence of this view was that any but wealthy venereal patients had 
extreme difficulty in obtaining treatment, and as a result many severe 
cases were found. This lack of treatment doubtless partiallj^ accounts 
for the supposed malignancy of venereal diseases of this period. 

Toward the end of the fourteenth century it would seem that the 
infectious nature of gonorrhea and the mode of its contagiousness 
were pretty definitely recognized. Numerous ordinances and police 
regulations for its control were in force, and medical supervision of 
houses of prostitution was inaugurated. At this time it would appear 
that a fairly definite distinction was made between syphihs and gon- 
orrhea. Owing to the prevalence of venereal disease James IV, in 
1497, issued his celebrated proclamation, banishing all the infected 
> Sanger: The History of Prostitution, 1906. 


from the city of Edinburgh. This proclamation, however, was prob- 
ably aimed at syphilis more than at gonorrhea. In London, in 1430, 
during the reign of Henry VI, a police regulation was in force excluding 
all venereal patients from public hospitals, and requiring them to be 
strictly guarded at night. Just how this guarding was to be carried out 
is not stated. In the reign of Henry VIII there were six lazar-houses in 
London for the reception of venereal patients. All were located some 
distance from the city proper. Toward the end of the fifteenth cen- 
tury Europe was swept by an epidemic of syphihs. So se^'ere and 
devastating was this, and of so mahgnant a character was the disease, 
that gonorrhea sank into comparative insignificance. Up to this time 
a definite distinction had been made by most authors between the two 

The sixteenth century, as regards venereal diseases, is generally 
looked upon as one of confusion. At this time syphilis, which was so wide- 
spread, was a comparatively new disease, and was but little understood 
by many physicians. It has previously been pointed out that the early 
writers paid but scanty attention to the occurrence of gonorrhea in 
the female, and with our present knowledge of the latency of this 
disease in the external genitalia of women, and the difficulty of diagnosis 
even with our present-day methods, the attitude of the earlier physi- 
cians can readily be understood. Endometritis and endocervicitis 
were regarded as uterine catarrh, and their etiologic association with 
gonorrhea was unknown. The intraperitoneal complications of gon- 
orrhea were not recognized. What wonder, then, that James Cuta- 
ncus, in 1504, stated positively that gonorrhea could be contracted 
from a healthy woman — an opinion shared by many eminent 
authorities at a much later date. Paracelsus,' as early as 1530, 
regarded gonorrhea as a complication of syphilis. This opinion 
was shared by Musa Brassavolus (1553), and later by his pupil, 
Gabriello Fallopius. In this view these physicians were almost 

However, from the appearance of the first epidemic of syphilis 
early in the fifteenth century, a general change seems to have taken 
place. Joannes de Vigol (1513), in his "Surgery," in Chapter de 
Auxiliis ^Egritudinum Virga?, writes in detail of gonorrhea and its 
treatment. Marcellus Camanus (1495), a military surgeon of the 
Venetian army during the period of the first epidemic of syphilis, and a 
physician of extensive experience in venereal diseases, and .\lexander 
B(Mic(Hctus (1510), both discu.ssed syphilis and gonorrhea separately. 

' I'aracel«ii.s: Von d. franzos. Kriink., Xurcmhurii;, 1.529. 


In 1527 Jacques de Rethencourt, of Rouen, wrote an interesting history 
of gonorrhea, and was the first to use the term venereal in conjunction 
with diseases pertaining to sexual intercourse. In England, Simon 
Fish (1530), Andrew Boord (1546), Michael Wood, and WiUiam BuUeyn 
(1560) describe gonorrhea, particularly in women, as a disease distinct 
from syphilis. During the sixteenth century gonorrhea seems to 
have been very prevalent in England, especially among the prosti- 
tutes. The disease was considered but a symptom of syphilis, and was 
so treated by such prominent writers as Petronius^ (1565), Martiniere- 
(1644), Sydenham' (1680), Devaux (1711), Turner^ (1717), and many 
others. As a result of this mistaken view, gonorrhea was treated 
vigorously with mercury, guaiac, and sarsaparilla. In a -treatise 
published in 1563 we read: "The final symptom of syphilis is Gallic 
gonorrhea — thirty years may elapse before the discharge begins." 
However, more rational views regarding the etiology of syphilis and 
gonorrhea were held by some of the more acute diagnosticians. 
P. Haschard (1554) wrote, warning against the prevalent treatment of 
gonorrhea by large doses of mercury, stating that, in his opinion, the 
diseases were distinct and separate. 

According to Stephenson,^ the recognition of the connection be- 
tween leukorrhea in the mother and ophthalmia in tlie infant dates to 
the year 1750, when G. S. T. Quellmalz" insisted upon the point. The 
fact was also mentioned by J. G. Goetz^in 1791, by C. G. Selle in 1793, 
and by A. Schmidt^ in 1806. Gibson^ also deserves credit for noting the 
clinical relationship between leukorrhea and ophthalmia. Morrison'" 
(1808) and Saunders'^ (1811) also wrote confirming these views. 
But it remained for Vetch,'- in 1820, to prove by experimental inocu- 
lation the truth of Gibson's assertion. Further references of historic 
interest regarding ophthalmia maj^ be found in the works of Simmons'' 

' Petronius: De Morb. Gallic, lib., September, 150.5. 
2 Martiniere: Traitd de la mal. veneriennes, 1664. 
" ' Sydenham: Epist. d. luis vener. Hist, et curat., London, 16S0. 
■"Turner: Syphilis, etc., London, 1717. 

' Stephenson, S.: Ophthalmia Neonatorum, London, 1907, p. 22. 
^ " Quellmalz, G. S. T.: Cent. f. prak. Augenheilkunde, February, 1S94. 
' Goetz, J. G. : De Ophthalmia Infantum recens natorum. 

» Schmidt, A.: Ophthalmologische Bibliothek (K. Himly u. J. A. Schmidt), 1806, vol. 
iii. No. 2, p. 107. 

' Gibson, B.: Edinburgh Med. and Surg. Jour., 1807, p. 160. 

- 10 Morrison: Med. and Physical Jour., 1808, vol. x.\, p. 57. 

" Saunders, J. C: A Treatise on Some Practical Points Relating to the Disease of the 
Eyes, London, 1811. 

- '2 Vetch: Practical Treatise on the Diseases of the Eye, 1820, p. 242. 

" Simmons, W.: Edinburgh Med. and Surg. Jour., 1809, vol. v, p. 283. 


(1809), Ware' (1814), Hagewisch.^RyalP (1824), Green^ (1824), Wat- 
son^ (1828), Wisharf^ (1829), Jacob^ (1834), CarmichaeP (1839), 
Edwards' (1840j, Lawrence'" (1844), Whitehead" (1847), Watson'- 
(1848), Oke" (1852), Tyler-Smith'^ (1853), Crede'= (1853), Mackenzie'^ 
(1854), Guyomor'' (1858), Walton'^ (1865), Wells"* (1865), Wilson^" 
(1866), Xoeggerath-' (1872), Hulke" (1873), Ballard^' (1859), Hogg" 
(1875j, Neisser" (1879), and others that have been collected by Steph- 
enson-^ in his excellent monograph. 

Until 1753 the prevailing opinion was that a urethritis was due to 
the presence of an ulcer within the urethra. At about the beginning 
of the eighteenth century the opposition to the incorrect views held 
regarding the etiology of gonorrhea and syphilis began to become more 
insistent. Nevertheless, it was not until the end of the eighteenth 
centurj' that the separate identity of these two diseases was generally 
accepted. At this time Finger and others write of the existence of 
two schools of syphilologists — the identists, who believed in the iden- 
tity of the virus of gonorrhea and of syphilis, and the dualists, who held 
the contrar}' view. Hales" (1770) advocated the complete separation 

' Ware, J.: Kemjirk.s on OphthalmjvlSU, p. 126. 

- Hagewisch: Horn's Arch. f. prak. Med., vol. iii, p. 208. 

' Ryall, J.: Trans, .\ssoc. of the Fellows and Licentiates of the King and Queens 
College of Physicians in Ireland, 1824, vol. iv, p. 340. 

* flrcen: Lancet, February 1.5, 1824, p. 213. 

' Watson, A.: X Compendium of the Diseases of the Human Eye, second edition, p. 34. 

" Wishart, J. H.: ICdinburgh Med. and Surg. .Tour., 1829, vol. xxxii, p. 253. 

'Jacob, A.: ■'Ophthalmia," in Cj'clopa'dia of Practical Mod. by Forbes, Tweedie 
and Conoll}', vol. iii, p. 198. 

' Carmichael, H.: Dublin Jour. Med. Sci., 1839, vol. xv, p. 200. 

» Edwards, C: Lancet, July 4, 1840. 

" Lawrence, W.: \ Treatise on the Diseases of the Eye, 1844, p. 22. 
"Whitehead, J.: Provincial Med. and Surg. Jour., 1847, p. .')3G. 
" Watson, T.: Lectures on the Principles and Practice of Physic, 1848, vol. i, p. 309. 
" Oke, W. S.: Provincial Med. and Surg. Jour., 18.52, p. 29. 
" Tyler-Smith, W.: Lancet, August 20, 1853, p. 157. 
'* Crcd(5: KHnische Vortrage iibcr Geburts., 1853, vol. i, p. IGO. 

" Mackenzie, W.: Practical Treatise on the Diseases of the Eye, fourth edition, 1854. 
" Ouyomor, D. : Tli6se de Paris, 1S58, p. 45. 
" Walton, IL: .Med. Times and Gazette, 18G.5, vol. i, p. .5.59. 
" Wells, J. S.: Lancet, 21, 1865. 

» Wilson: Dublin (iuarteily Jour. Med. Sci., 1866, vol. xhi, p. 184. 
" Noeggerath, E.: Die latentc (ionorrhoe iin weiblichen (leschlciht ; also Trans. 
Amor. Gyn. Soc, 1876, vol. i. p. 26S et .seq. i 

" Hulke: Med. Times and Gazette, 1873, vol. ii, p. 629. 
-' Hallard, J.: Brit. Med. Jour., 1859, p. 411. 
" Hogg, .1.: Med. Press and Circ, March 31, 1875. 
■' Neisser, A.: Cent. f. med. Wi.ssens., July 12, 1879. 
■' Stephen.son, .S.: Ophthalmia Xeonalonun, London, 1907. 

■'Hales: Salivation not Necessary for the Cure of Venereal Diseases, etc., London, 
1764; also letter addres.sed to Caesar Hawkins, etc., London, 1770. 


of gonorrhea and the chancre virus. EUis, in 1771, conducted a series 
of experiments that strengthened the beUef that these were two dis- 
tinct diseases. Bayford, in 1773, wrote opposing Ellis's views, basing 
his conclusions on the fact that he was unable to detect with the 
microscope any difference between gonorrheal and syphiUtic pus. 
Tode (1774) combated the identity of gonorrhea and syphilis. Dun- 
can (1777) advanced the argument that the inhabitants of Otaheite 
were familiar with syphilis long before gonorrhea was introduced 
among them. Mr. Wilson, surgeon to H.M.S. Porpoise, visited 
Otaheite in 1801, and after a careful investigation came to the con- 
clusion that gonorrhea was then unknown on that island. Harrison 
(1781) and Swediaur (1784) employed the experimental method, but 
their results led them to suppoi-t the view that syphilis and gonorrhea 
were identical. 

Sir John Hunter^ became deeply interested in this controversy, 
and on a Friday morning in May, 1767, performed the famous experi- 
ment that was destined to retard the medical progress of his day for 
many years. Hunter offered himself as a sacrifice for the cause under 
dispute. He made two punctures in his penis with a lancet dipped in 
venereal matter taken from a supposed case of gonorrhea — one punc- 
ture was made in the glans and the other in the prepuce. As a result, 
he developed syphilis. The inguinal glands became enlarged, a 
mucous patch appeared on one tonsil, and a copper-colored rash de- 
veloped. As a consequence of this experiment Hunter came to the 
conclusion that syphilis developed from gonorrhea. The suggestion 
is made by Palmer- that Hunter, during one of the repeated dressings 
of the wounds on the penis, may have inoculated the sores with syphi- 
litic virus. The other — and the more likely — explanation seems to be 
that a urethral chancre was in the first place mistaken for a gonorrhea. 
In view of Hunter's upright character and well-known veracity no 
other explanation is tenable. There can be no doubt that Hunter, 
although a keen observer, was impulsive, and likely to form hasty 
conclusions. Hunter' was considered at this period the first surgeon, 
the first physician, and perhaps the first scientist in all Europe. So 
well known was he, and so large a following had he, that this "personal 
experiment" could not fail to carry great weight, even with those who 
believed in the separate identity of gonorrhea and syphilis. It is true 
that Hunter distinguished between a "venereal" and a "simple" 
gonorrhea, and believed that the latter could develop from causes 
other than coitus, or even spontaneously, but he did not describe his 

' Hunter: Works, edited by John Palmer, New York, 1841, vol. ii. 

= Hunter: Loc. f?7. Ulunter: Loc. cit. 


differential diagnosis clearlj'. He considered gleet non-infectious. It 
seems a cruel irony of fate that Hunter, after sacrificing himself for 
the cause of science, should have been forced into the position of the 
leader of a movement that has since been proved to have been a retro- 
gression involving some sixty years. 

Even so late as 1829 mercury was used in the treatment of gon- 
orrhea in some of the large London hospitals, notwithstanding the fact 
that the Edinburgh school, through such men as Hales (1770), How- 
ard' (1787), and Bell- (1793), taught that gonorrhea and syphihs were 
different diseases. Hogan's (1787) opposition to Hunter's doctrines 
went unnoticed. In 1793 Benjamin BelP conducted a series of experi- 
ments that attracted considerable attention. Among other evidence 
that he adduced pointing to the separate identity of gonorrhea and 
syphiUs was an experiment made upon two physicians, in whom gon- 
orrheal pus was inoculated into the urethra, and neither of whom de- 
veloped syphihs. Clossius (1797) coincided with Bell's conclusion. 
Evans and Le Bon (1789), by their experiments, strengthened Bell's 
position. Herandez (1811) inoculated seventeen convicts with gon- 
orrheal pus and all developed gonorrhea. Not one contracted syphilis 
as a result of the test. This was undoubtedly a most important ex- 
periment, and carried great weight with the mecheal profession in 
general. A new dispute now arose. C'aron (1811), Desruelles (1826), 
and Devergie (183(5) taught that gonorrhea was devoid of any specific 
virus, and that it was not a contagious disease. The careful and exact 
Germans had by this time come to the conclusion that gonorrhea was 
an entirely different disease from syphilis. They, however, denied its 
local character and regarded it as a general infection. In the works 
of Autheuriet (1809), Ritter (1819), and Eisenmann (1830) we find 
descriptions of various sequela; or metastases of urethritis, such as 
gonorrhea of the lung, ear, and meninges, gonorrheal ulcer, neuroses, 
amaurosis, and congenital and acfiuired gonorrheal diatheses. Thus 
matters remained in this unsettled state until Phillippe Hicord' (1831- 
1837), with his large ('Xi)erience, Ijrilliant critical and dialectic powers, 
impressed his teachings forcibly on the medical profession. This in- 
ve.stigator made (j()7 inoculations of gonorrheal pus and in not a single 
case did syi)hilis result. In later experiments the .same writer showed 

' Ilowiird: I'nii-liiiil Obscrviilions on the N:iliiial History ami Ciiir of the 
OisciiMcs, Lonildii, 17s7. . 

' Hell: A Trciitisc on (ionorrlica, KdinliurKh, i''Xi; ilntl.: on (!iii. \ iiul. anil 
I ncM. London, 17M. 


' KiconI: Lectures on \'enereal anil(>llier 1 Jiseases Arisiiiu from Sexual InlcMcourse, 
l'liila<lil|>liia, ISttl. 



that a urethral sore could furnish pus from which syphiUs might de- 
velop. These experiments practically estabhshed the non-identity of 
gonorrhea and syphilis. No one can fail, on reading Ricord's works, 
to be impressed with his ability and with the bull-dog tenacity of 
purpose with which he brings his conclusions to the foreground. 

Attention has previously been drawn to the fact that the early 
writers paid but little regard to gonorrhea in the female, and it was not 
until Noeggerath's^ epoch-making observations were published in 
1872 that the full significance of gonorrhea in women was realized. It 
is true that in 1857 Bernutz and GoupiP reported their observations 
of gonorrheal infections of the appendages and pelvic peritoneum, and 
that in 1858 West published a paper in which he ventured an opinion 
that in some cases gonorrhea might extend to the intraperitoneal gen- 
erative organs. This view was subsequently supported by Dobson, 
Nelson, and Giles, but received little support from the profession in 
general. This was doubtless due to the fact that in the male a gon- 
orrheal urethritis is an active and usually painful condition, and that 
a very large proportion of urethral discharges occurring in men are of 
gonorrheal origin, whereas in women urethritis or cervicitis was of 
itself of httle moment, and rarely produced severe subjective symp- 
toms, and that leukorrhea may be the result of a variety of causes. 

As has been pointed out in previous pages, Ricord's numerous ex- 
periments and acute reasoning, together with the brilliant and perti- 
nacious manner in which his conclusions were presented before the 
medical world, definitely established the separate identity of gonorrhea 
and syphihs, notwithstanding the fact that a few stubborn identists, 
such as Eisenmann, Vidal de Cassis, Simon, and Caron, were still 
occasionally heard from. 

For many years prior to the victory of the unitists, headed by Ri- 
cord, two forms of urethritis had been recognized by Hunter,' Brassa- 
volus, and others. These two varieties were spoken of as gonorrhoea 
virulenta and gonorrhoea simplex. Now that the gonorrhoea viru- 
lenta, or syphilis, was satisfactorily accounted for, the question arose, 
was the gonorrhoea simplex, or, to avoid confusion, was gonorrhea, 
caused by a specific virus, or was it merely the result of a simple irri- 
tation? Ricord taught that gonorrhea was not a specific disease, but 
was a simple catarrh that might be due to the action of various irri- 
tants on the mucous membranes. Indeed, one physician of this 
period has stated that, in his opinion, gonorrhea might follow the 
exposure incident to urination in the night air. It is significant, and 

' Noeggerath, Emil: Die latente Gonorrhoe in weiblichen Geschlecht, Bonn, 1872. 
- Bernutz and Goupil: Arch. g(?n. de Med., March, 1857. ' Hunter: Loc. cit. 


shows the result of Ricord's keen powers of cUiiical observation, that 
he regarded the chscharges from uterine catarrh, the lochia, and the 
menstrual flow as peculiarh' likely to set up a urethritis, conditions that 
we now know favor contagion in cases of chronic gonorrhea in women. 
Under predisposing causes of gonorrhea he mentioned age, sex, tem- 
perament, climate, and the season of the year. Certain food-stuffs, 
such as alcohol, asparagus, salty foods, and rich dishes in general, were 
likely to set up a urethritis. Among the chief irritants Ricord placed 
gonorrheal pus first. This he believed would produce gonorrhea, not 
by its contagiousness, but merely by the irritation it caused. He 
maintained that a similar effect could be produced by instrumentation 
of the urethra, bj^ the injection of irritating fluids, sexual excesses in 
healthy individuals, or even prolonged sexual excitement without 
gratification. To bear out these conclusions Ricord pointed to the 
fact that he had frequently seen urethritis in the male, and on examin- 
ing the female partner had found her entirely healthy and free from 
disease. He also believed that a patient could in time become accus- 
tomed to the irritant, and might thus cohabit with the infected woman 
without harmful results, whereas another would immediatelj^ develop 
a gonorrhea — a fact that is now well estabhshed. Ricord believed 
that blondes are more susceptible to gonorrhea than brunettes, and that 
women with leukorrhea are prone to be infectious. He thought that 
rich foods, alcohol, especially the white wines, frequent intercourse, a 
subsequent warm bath, and urethral injection were factors that fa- 
vored infection. 

As late as 1883 Mr. Henry Lee, in an article in "A System of Sur- 
gery" edited by Holmes, makes a statement confirming Ricord's 
views, and concludes as follows: "Gonorrhea often arises •frf)m inter- 
course with women who themselves have not the disease." 

To return, however, to the time of Ricord: We find that there were 
two distinct schools regarding the genesis of gonorrhea — the one be- 
lieving with Ricord that urethritis resulted from a simi)le irritation, 
and the other that the virus of gonorrhea was the etiologic factor. 
These contrary theories led to the performance of many experiments. 
Voilleniier^ anointed a sound with pus from an abscess of the neck and 
introduced this instrument into the healthy urethra of a man, keeping 
it in place for one hour. No ill results followed. This experiment was 
repeated upon another individual, except that pus from an abscess of 
the thigh was used. A negative result was obtained. It was ascer- 
tained, however, that when a urethra was inoculated with pus from a 
vuelhritis, gonorrhea invariably followed. A similar result was ob- 
' Voilldiiicr: Trait ^' dcs ninladics dcs voies urinaircs, Paris, 1S()8. 


tained with pus from a case of ophthalmia by Thiry, Pauh, Vetch/ 
de Landau, Otis, and Guyomor,^ all of whom recognized the analogy 
between the two conditions. RosoUmes^ and Michaelis observed that 
sexual excesses did not produce gonorrhea. Milton,'' who for many 
years was the sole practitioner in a small country town, never saw any 
gonorrhea other than imported cases, and he assures us, as Spooner 
aptly phrases it, that the inhabitants were not averse to " Wein, Weib, 
und Gesang." Further arguments were deduced from the fact that 
virulent gonorrhea had a definite period of incubation and ran a pro- 
longed course, whereas urethritis the result of chemical or traumatic 
irritants appeared almost immediately and tended toward a rapid 
spontaneous cure. 

In this state the controversy continued for over forty years. Such 
eminent authorities as Fournier,^ Acton,^ Robert,' Jullien,* Langlebert,* 
Geigel,'" Muller, Tarnowsky,^^ and Bumstead'^ were among the anti- 
virulists, and believed that gonorrhea was caused by a simple irritant, 
whereas among the virulists were Hoelder, Reder," Baume, Milton," 
Martin and Belhomme," Lebert, Zeissl," Diday," Sigmund, Auspitz, 
Durkee, and Duyon.'* 

It was, however, impossible to escape the fact that whenever pus 
from a virulent urethritis was introduced into a healthy urethra a 
urethritis followed, and that the resulting infection presented certain 
chnical characteristics similar to the original case, and differing quite 
radically from a urethritis caused by a chemical or traumatic irritation. 
It was also found that the amount of pus used in the inoculation made 

I Vetch: Practical Treatise on Dis. of the Eye, 1820, p. 242. 

' Guyomor: These de Paris, 1858, p. 45. 

' RosoUmes: Annalcs de Dermatologie, Paris, 1883, p. 20. 

■■Milton: Gonorrhea, London, 1876; also Path, and Treat, of Gonorrhea, London, 
1883, 2. 

' Fournier: Dictionary de Med. et de Chir. Pract., 1866, Art. Blennorhce. 

*.\cton: A Practical Treatise on Diseases of the Urinary and Generative Organs, 
London, 1851, p. 30. 

' Robert: Maladies Veneriennes, Paris, 1861, p. 64. 

' JulUen: Traite Practiqvie d. Mai. Veneriennes, Paris, 1879. 

' Langlebert: Maladies Veneriennes, Paris, 1864, p. 16. 
"• Geigel, A.: Geschich. Path. u. Therap. d. Syph., Wurzburg, 1867, p. 73. 
" Tarnowsky: Vort. ii. ven. Krank., Berlin, 1872, p. 87. 
" Bumstead: Venereal Diseases, Phila., 1879, also 1883, p. 56. 
" Reder: Path. u. Therap. d. ven. Krank., Vienna, 1863. 

"Milton: Gonorrhea, London, 1876; also Path, and Treat, of Gonorrhea, London, 
1883, 2. 

'* Martin and Belhomme: Traite Pract. et Elem. de Path. Syph., Paris, 1864. 
" Zeissl, von: Comp. d. Path. u. Therap. d. prim. Syph. u. einf. ven. Krank., Vienna, 

" Diday: Mai. Ven. et Cutanee, Paris, 1876, p. 4. 
i« Duyon: Mai. Ven. et Cutanea, Paris, 1876, p. 4. 


no difference, just as virulent a urethritis being caused by an infinitesi- 
mal amount as by a large quantitj'. These facts were strong argu- 
ments for the viruhsts, and as time went on this faction grew stronger. 
The work of Koch, Halher,' Belhomme and Martin,- Pasteur, and 
Klebs began to make itself felt, and the younger and more scientific 
men turned to the laboratory in the hope of finding there the proof that 
would end this lengthy discussion. 

In 1658 a Jesuit, Athenasius Kircher,^ described "vermiculi" in 
the pus from syphilitics, but what he saw were probably pus- or blood- 
cells, which up to this time had not been discovered. Deidier,^ in 1710, 
beUeved syphilis to be due to the presence of small maggots: "These 
hatch and produce others, and in this way we can assume the propaga- 
tion of the venereal virus. How otherwise can the fact be accounted 
for that pox could be carried from the Orient into Europe and then 
pass by commerce with a single prostitute into the French army and 
thus to France, unless by these venereal worms which are constantly 
laying great numbers of ova?" "So naive the conception and so cor- 
rect is the chain of thought devised that this man divined what could 
not be proven until two hundred years later" (Finger). 

Some authorities believed that the Marseilles epidemic of 1721 
was caused by animalcula. Five years later a satire appeared in 
Paris that threw ridicule upon the entire subject. Certain parasites 
which he called the "Vibrio lineoa" and the "Trichomonas vaginalis," 
and which he discerned in gonorrheal leukoi-rhea, were described by 
Donne' in 1837. For some time these organisms held the field as the 
cause of vaginitis, but seven years later we find Donne of the oi^inion 
that gonorrheal pus differs in no respect from ordinary pus, and that 
the "Trichomonas" which he had described were the inhabitants of 
the normal vaginal secretion. 

At about this period the erroneous view became prevalent that tlic 
vagina was the chief seat of gonorrhea in women. If the urethra and 
liladder were not macroscopically involved, and if no gross changes 
were found in the vagina, the surgeons of the day were inclinetl to 
give the patient a clean bill of health so far as gonorrhea was concerned. 
In fact, gonorrhea in women was looked upon as a comparatively in- 
significant disease. Cervicitis, endocervicitis, and uterine lesions were 

' lliillicr: Zcit.schrift f. Panusitcnk., 1S72. 

• Holliomtiic iiiul Martin: Trait<! I'ract. ct lOlctn. lic I'atli. Sy|)li., I'aris, IStil. 

• Kirrher: .Scrutinium Physico-mcdiciiim C'onla({ionc.>( liiis, (iiiac postis dicitiir, i-tc, 
Rome, ie.')8. 

' Dcidicr: Vim. Med. S. L. Maladies Vcnpricnnrs, I'aris, 1710, p. l:{. 
'Doiinc: Hrch. .Micr. s, 1. Nalur. d. Mucus r. 1. Maticr d. divers Kcoul. d. Orijaii. 
lienito-uriii., etc., I'aris, ls:{7, also ( 'ours d. .Micros., ISl 1, p. 201. 


classed as uterine catarrh, a condition believed to be quite separate 
and distinct from gonorrhea. By only a few observers had the con- 
nection between pelvic peritonitis and gonorrhea been even hinted at. 
It requires but Uttle imagination to grasp the vast social importance 
of this mistaken viewpoint of the pathology of gonorrhea. In the male, 
pus was regarded as the infective agent, and while this was present in 
a urethritis, intercourse was interdicted. The opinion advanced by 
Lee, that "so long as any discharge exists, sexual congress is unsafe," 
was not generally accepted, and may be looked upon as representing 
the most advanced view of this period. "Not only does the medical 
world believe that a so-called cured gonorrhea is actually cured, but 
they are even of the opinion that a man who has a gleet (Nachtripper) 
may not infect his wife. It is usual, at the present time, among the 
best informed practitioners (non-specialists), to sanction marriage in 
the case of men who still continue to observe adhesions of the urethral 
orifice and staining of the linen, as beaux restes of a gonorrhea. Even 
the highest authorities, as Professor A. Geigel,^ permit the cohabita- 
tion with the newly married wife of a man, the subject of gleet, so soon 
as the urethral discharge appears perfectly clear" (Noeggerath^) . 
This quotation has been introduced in full, as it exemplifies so thor- 
oughly the general opinion of the medical profession regarding the 
contagiousness of gonorrhea at this period. 

In 1872 Emil Noeggerath,' a German physician and former prac- 
titioner in New .York, published a work on gonorrhea that was destined 
to revolutionize the view of the medical world regarding the clinical 
significance of the disease, more especially of gonorrhea in the female. 
Unfortunately for English readers this treatise was published in 
German and has never been translated. This may, in part, account 
for the slow recognition which this epoch-making monograph received. 
This writer's views regarding gonorrhea were in some respects exag- 
gerated, and, like many another man in a similar position, these 
portions of his paper were widely quoted and branded as false, whereas 
the wide-reaching and accurate clinical observations were allowed to 
pass more or less unnoticed. Noeggerath was the first to insist that 
inflammation of the uterus and appendages was the direct result of 
gonorrhea, and that gonorrhea was extremely intractable to treat- 
ment; that it often remained latent for months or years before causing 
severe complications, and that infection the result of sexual intercourse 
might result after long periods of quiescence. Of this he writes: "Of 

' Geigel: Geschich. Path. u. Therap. d. Syph., Wurzburg, 1867, p. 73. 

^ Noeggerath, Emil: Die latente Gonorrhoe in weib. Geschlecht, Bonn, 1S72. 

' Noeggerath: Loc. cit. 


one hundred women who become the wives of men who have formerh' 
been afflicted with gonorrhea, scarcely ten remain healthy. The rest 
suffer from one of the ailments which it is the task of this treatise to 
describe." To bear out these conclusions he presents notes of 50 
selected cases. His classification of intraperitoneal pelvic gonorrhea — 
into: (1) Acute perimetritis; (2) recurrent perimetritis; (3) chronic 
perimetritis; and (4) oophoritis — was undoubtedly faulty. Never- 
theless his conception of the nature of gonorrhea was correct; thus he 
says: "A woman who at any time in her life has had an acute gon- 
orrhea has to expect at some more or less distant period — it may be a 
month or a year — a subsequent attack of peritonitis in some form, and 
that the wife of a man who has ever suffered from gonorrhea is, with 
regard to an attack of perimetritis, in the same position as if she her- 
self had had an acute gonorrhea." He dwells strongly on this point, 
and goes on to say: "The young, hitherto healthy wife, begins to 
complain a few weeks after marriage. Menstruation commences to 
be more profuse than formerly, accompanied by dysmenorrhea. 
Leukorrhea becomes more or less excessive, especially after the periods. 
This gradually increases, ultimately becoming continuous without in- 
termission until the next menstruation begins. After a few months 
severe pain commences in either or both sides of the pelvis, and the 
sufferer is ultimately compelled, on account of fever and unbearable 
burning pains in the abdomen, with increased leukorrhea, to take to 
her bed and send for medical assistance. According to the severity of 
her attack she remains confined to her bed for weeks or perhaps for 
months, with exhaustetl strength, struggling for life, ultimately re- 
covering, but remaining sterile and invalided for the remainder of her 
days." Noeggerath points to the freciuency with which sterility 
follows gonorrheal infections in women, and shows that when preg- 
nancy does occur, the sub.sequent labor is often followed by sepsis. 
There can be no doubt that during this period gonorrhea was extremely 
prevalent in New York. Nevertheless, the statement of Noeggerath, 
that 80 per cent, of married men have had gonorrhea at some time 
during their lives, that 90 per cent, of these are uncured, and lliat (id 
per cent, of all married women have been infected with gonorrhea, 
seems to be the view of a pessimist. The conclusions he arrived at in 
this masterly essay are as follows: 

1. (ionorrliea in the man, as well as in tlic woman, persists for the 
whf)le lifetime, in spite of api)arent cure. 

2. Latent gonorrhea occurs in man as well as in woiiiaii. 

■?. Latent gonorrhea in 1 he man, as well as in tlic unman, may 


evoke in a hitherto liealthy individual either a latent or an acute 


4. Latent gonorrhea in the woman manifests itself m the course ot 
time by perimetritis, acute, chronic, or recurrent, or by oophoritis, or as 
a catarrh of some definite portion of the genital mucous membrane. 

5. The wives of men who at any time in their lives have had gon- 
orrhea are, as a rule, sterile. 

6. Such women, if they do become pregnant, either abort or bear 
but one child. Only very exceptionally are more born. 

7. From the discharge of a woman affected with latent gonorrhea a 
fungus may be cultivated that is analogous to that obtained from the 
discharge of acute gonorrhea. 

Noeggerath lived to modify his views regarding the prevalence and 
incurability of gonorrhea. It is certain that he strongly suspected the 
nature of the etiologic factor of gonorrhea, and that had he been 
famiUar with Koch's methods of investigating microorganisms, Neis- 
ser's discovery might have been anticipated by seven years. In the 
year following the appearance of Noeggerath 's work Macdonald' 
published a paper strongly confirming the views of the former. But 
with the caution for which his countrymen are noted, Macdonald 
hesitated to confirm all Noeggerath'« extreme opinions. In writmg 
of the etiology of gonorrhea, Macdonald made this prophetic state- 
ment: "It does not seem in the least Utopian to anticipate that some 
day we shall be able to see with the microscope the germs, whether 
they be one or many species, which give rise to the blood changes 
which give rise to puerperal fever and other septicemic disorders." 

In reviewing the history of gonorrhea, there are three men whose 
names stand out above all others. The first of these is Ricord, who 
definitely established the identity of gonorrhea, and thus placed its 
treatment and that of syphilis, with which it had previously been con- 
founded, upon a sound basis. The second great advance in the study 
of this disease is due to the epoch-making monograph of Noeggerath. 
The latter's work was strictly chnical; to him we are indebted for 
estabhshing the relationship existing between pelvic peritonitis and 
gonorrhea, for pointing out the long-continued contagiousness of this 
disease, its latency, and its devastating results with regard to sterility 
and puerperal infection. The third name in this great triad is that 
of Neisser. Noeggerath was fortunate in having Neisser's discovery 
come when it did, for it enabled him to confirm his clinical work 
by exact laboratory researches. As Bumm has happily remarked, 
"Noeggerath was more fortunate than Semmelweis: he lived to see 

> Macdonald, Angus: Edinburgh Med. Jour., June, 1S73. 


the triumph of his observations. For this he has to thank Neisser, 
who soon after discovered the gonococcus and made possible the cer- 
tain proof of his statements relative to the frequency' of the lesion." 

Early in 1872 Hallier' reported the finding of a micrococcus in 
gonorrheal pus. Some of these cocci were free and others were intra- 
cellular. Owing to insufficient laboratory facihties, such as staining, 
illuminating, and magnifying, these results attracted Uttle attention, 
and to Neisser,^ seven j-ears later, is very properly attributed the honor 
of the discoverj' of the gonococcus. 

Another name that has been more or less overlooked in tliis con- 
nection is that of Salisbury ,5 who, in 1868, stated that for six years he 
had been examining the urethral discharges from cases of urethritis. 
Salisbury writes : "I had not been pursuing this mode of inquiry long 
before I discovered spores which were scattered about free in the pus 
and in the epithefial cells. . . . These spores are very minute 
and well defined; they are often discovered in twos and sometimes 
in fours. ... In some instances the pus-cells become filled with 
the spores." This observer obtained his material for examination by 
scraping the urethra. It seems that, undoubtedly, he really saw the 
gonococci, but failed to receive proper recognition through lack of proper 
staining methods. He also described filaments which he believed re- 
sulted from the "spores." He believed that every drop of gonorrheal 
pus contained specific poison. His illustrations, while showing some 
of the spores in pairs, present others that appear in groups, without 
definite pair formation. His description is, however, convincing. 

On July 12, 1879, Albert Neisser, at that time an assistant in the 
University Clhnic of Dermatology at Breslau, described a micrococcus 
that he believed to be the cause of gonorrhea. His conclusions were 
drawn from the study of 35 cases. In only one case of urethritis in 
the male was the micrococcus not found, and this case was suspected 
from the first of being one of urethral chancre. In 9 cases of urethritis 
in the female the micrococcus was found in all. It was also demon- 
strated in 7 cases of purulent ophthalmia. Control examinations were 
made, but in no case was the micrococcus discovered. To demon- 
strate these micrococci Neisser employed the method of Koch. A small 
drop of pus was spread thinly over a cover-glass and allowed to dry. 
It was then stained with an aqueous solution of methyl-violet and 
again put aside until dry. Neisser described the micrococci and their 
method of division accurately. This discovery, coming as it did at 

' Ilallier: Zeitschr. f. Piiriisitciik., 1S72. 

- .\eis.ser: Cent. f. d. nied. \Vis.ioii., July 12, 1879. 

' SalLslmry, .J. H.: .\iiicr. .lour. Mc<l. .Sci., 1SG8, pp. 17-25. 


a time when the Germans were so confidently expecting great results 
from the new era of bacteriology introduced by Koch, attracted uni- 
versal attention, and many investigators immediately took the field. 
Cheynei reported that in 1879 he had discovered the gonococcus. 
Unfortunately, his publication did not appear until July 24, 1880. 
In 1880 Weis observed gonococci in the pus from 35 cases of urethritis. 
In only one case of urethral discharge were the gonococci not found, 
and this proved later to be a case of urethral chancre. He endeavored 
to find gonococci in the leukorrhea from 35 cases, but failed in every 
instance. In 1882 Neisser- pubUshed a second paper, in which he 
confirmed nearly all his previously published views. He insisted that 
the micrococcus previously described by him differed functionally and 
morphologically from all other organisms. He showed that the gono- 
cocci could be cultivated on artificial media, and that he himself had 
grown them for seven generations on cultures made from meat extract, 
peptone and gelatin of neutral reaction. Numerous experiments 
that he made on lower animals all failed. From 1879 to 1886, or even 
later, the literature relating to the gonococcus is extremely abundant. 
Thus Bumm^ mentions that there were 52 contributions on this subject 
up to the beginning of 1886, and Sinclair^ found 40 papers on ophthal- 
mia neonatorum alone abstracted in the Centralblatt fiir Gynakologie 
from 1881 to 1886. As might have been expected, all Neisser's con-, 
elusions were "not immechately accepted. Even so late as 1890 con- 
siderable doubt still existed in the minds of many investigators regard- 
ing the role played by the gonococcus in the production of gonorrhea. 
Bokai and Finkelstein" (1880) found micrococci constantly present 
in gonorrheal pus and in the secretion of ophthalmia. They made 
cultures, and from these inoculated the urethras of 6 medical students. 
Of these, 3 developed gonorrhea. In 1 of the 3 negative cases the 
urethral' discharge was found to contain oil of eucalyptus, which is 
toxic to gonococci. In the other 2 cases the failures were probably 
due to faulty technic. During this year (1880) further confirmatory 
work appeared from Ehrlich,'^ Rucker,' Aufrecht,** and Gaffky. In 

1 Cheyne: Brit. Med. Jour., July 24, 1880, p. 114. 

2 Neisser, A. : Deut. med. Wochenschr., 1882, vol. xiii, p. 279. 

3 Bumm: Beit. z. Kenntniss d. Gonococcus, Wiesbaden, 1885; also Der Mikr 
organismufd. gonorrhoischen Schleimhaut-Erkrankungcn, Gonococcus Neisser, secon. 
edition, Wiesbaden, J. F. Bergmann, 188/. , ,, , jc 

« Sinclair, N. J.: On Gonorrheal Infections in Women, in Wood .s Med. and hurg 
Monographs, 1889, vol. i. 

-' Bokai and Finkelstein; Orvosi Helilap, May 16, 1880; also Pester Med.-Clur. Presse 
June 20, 1880. 

« Ehrlieh: Zeit. f. klin. Med., 1881, vol. ii, p. 70. 

' Rucker: Deutsch. med. Wochenschr., 1880. 

» Aufrecht: Path. Mittheil., Magdeburg, 1884, p. 147. 


1881 Hirschljerg and Krouse^ found the gonococcus in all cases of oph- 
thalmia neonatorum examined, but claimed to have discovered mor- 
phologically similar micrococci in the vaginal secretion of healthy 
women. Haab- also found the gonococcus present in the pus from a 
large series of cases of ophthalmia neonatorum. Slatter^ and Langle- 
berf confirmed Neisser's conclusion. In 1882 Leistikow/ an assist- 
ant in the clinic for syphilis in the Berlin Charite Hospital, studied 
gonococci in the discharges from 200 cases of urethritis, 3 cases of 
ophthalmia in adults, and 4 eases in children. As a result of his in- 
vestigation this writer came to the conclusion that the microscopic 
demonstration of the presence of the gonococci absolutely proved the 
character of the infection. Krouse« (1882) and Konigstein" (1882) 
experimented by means of cultures and inoculations. In almost all 
cases in which cultures were inoculated into the eyes of animals, 
negative results were obtained. Konigstein did not agree with Neisser 
in believing that the diplococcus was characteristic of a gonorrheal in- 
flannnation of a mucous membrane. Ecklund^ asserted that he found 
gonococci in the secretions from cases of stomatitis, chronic enteritis, 
and even of inflammation of the lungs. It is very evident, from his 
paper, that his conclusions were drawn as much from his imagination 
as from fact. In the following year (1883) Bockhart,' of Wurzburg, 
accurately demonstrated for the first time the pathologic changes 
produced by the gonococcus. With a pure culture of this micrococcus 
he inoculated the healthy urethra of a forty-six-year-old male paralytic, 
whose death was daily expected. Two days after the injection of the 
gonococci the meatus became red and swollen, and by the sixth day 
a well-developed purulent urethi-itis was present. This increased in 
.severity until the twelfth day, wli(>ii the patient died. From the thirtl 
day following the inoculation gonococci in pure culture were secured 
daily from the urethral discharge. From a microscopic examination 
of the tissues of the urethra Bockhart'" concluded that the gonococci 
penetrated between the epithelial cells into the lymph-spaces of the 
mucosa and subnnicosa of the fossa navicularis, and that they here 

' Hirsriibcrg aiiij Krousc: Cent. f. pnikt. Augpiihoilk., 1881, vol. v, p. 39. 
'Haab: (Vnt. f. piakt. .VuKcnhoilk., Soptombcr, ISSl; Corrrspomlonzl)!. f. Scliwii/.cr 
Aerztc, vol. ii, p. SO, I'"cstsflir., Wirabaclcn, 

'Slatlcr: Sili!iiii«shcr. d. XIV. Ophllial. (Icscllscli. in Ihuh-Wwvii. pp. 0, .")1. 

' LanRlf'fjcrt: M.-iladics vcncricniics, Paris, ISdt, p. Id. 

'Lewtikow: Charil(;-,\niialcn, Berlin, 18S2, vol. vii, p. 7.")0. 

' Krousn: Cent. f. .VuRcnhoilk., 1882. 

" KoiiiK.slcin: Vorlrag, nclialt. in d. K.K. Gesoll. d. Aerzte, Vienna. 

I ikliind: Aiinal. d. Dermal., Pari.s, 1882, vol. iii, p. .540. 
' liockharl, .M.: Viertelj. f. Dermat. u. Syph., Vienna, 188:5, vol. x, p. .3. 
'"Bockliart: Sil/.uiin.slMriclil il. pliy.s. mod. Ge.sellschaft zu WiirzImrK, 18S.S, No. 1. 


multiplied and set up a leukocytosis; that the gonococci entered the 
white blood-corpuscles, and were thus disseminated to various tissues. 
Young' has questioned the correctness of the bacteriologic diagnosis 
of this case. 

Bockhart also published a report demonstrating the presence 
of gonococci in the discharges of 258 cases of chronic urethritis. 
Four years later (1886) Bumm gives the following description of 
the histologic picture produced by the gonococcus,. and its means 
of dissemination from the surface to the deeper layers: The in- 
fecting secretion conveys a certain number of gonococci to the 
mucous membrane. These penetrate the layers of epithelial cells, 
and reach the papillary body of the mucous membrane, passing 
through and between the protoplasm and cement substance of the 
epithelial elements. Swarms of white blood-corpuscles emigrate at 
this time from the dilated capillary network, which extends almost to 
the epithelial covering, and penetrate into the upper stratum of the 
connective tissue, whence, laden with gonococci, they pass through 
the epithelium to the surface. The epithelial stratum, whose firmness 
is destroyed by the proliferation of cocci, becomes fissured by the 
stream of fluid accompanying them and rises in clumps; this process 
may be aided by capillary hemorrhages between the epithelium and 
cellular tissue. The distribution of the cocci is confined to the super- 
ficial laj^ers of the subepithelial cellular tissue, where they are arranged 
between the fibers in rows or round colonies. While the micrococci 
increase in this manner in the outermost layers of the connective tissue, 
the inflammatory symptoms increase in intensity, and the round-cell 
infiltration finally occupies the entire papillary body, cell being closely 
applied to cell. This furnishes the transition to the purulent stage, 
in which the majority of the gonococci are washed away by the abun- 
dant suppuration. After a variable time regeneration begins to take 
place from the remains of the original epithelium, and by its extension 
puts an end to the further spread of the cocci in the tissue, whereas 
the migration of the pus-cells, which carry off the remainder of the cocci, 
proceeds uninterruptedly. With the regeneration of the epithelium 
are usually associated proliferating processes, from the lowermost 
layers of which epithelial papilliE grow into the connective-tissue sub- 
stratum. At this time the cocci, with the aid of the pus-cells, have 
disappeared from the papillary bodies, and are found only in the upper 
layers of the epithelial covering. But if the fresh epithelial covering 
cannot withstand an invasion of migrating round cells induced by 

'Young, H. H.: The Gonococcus: Report of Successful Cultivations, Contributions 
to the Science of Medicine, dedicated by his pupils to W. H. Welch, Baltimore, 1900, p. 677. 


external irritants, its continuity will suffer, and a new lesion of the 
papillary body produced by cocci will take place — i. e., a relapse occurs. 
During the latter part of the purulent stage and during the entire 
mucopurulent stage the proUferation of gonococci takes place outside 
of the tissues, upon the surface of the epithelium and in the secretion. 
Corroborative evidence of the etiologj^ of gonorrhea and ophthal- 
mia neonatorum appeared at about this time (1882) from the pen of 
Eschbaum,^ Newberry,- Bareggi, jNIarchiafava,' Campona, and Kej'- 
ser.'' The last of these writers examined the urethral discharge from 
64 cases of urethritis, — 30 whites and 34 negroes, — and found the 
gonococcus in all. They were absent in 3 other cases, 2 of which had 
been treated, and in the third little discharge was obtainable. In 
1883 Sternberg" appears to have mistaken the Micrococcus catarrhalis 
for the gonococcus, and as a result denied the specific character of the 
latter. Welander* examined 144 cases of urethritis in the male and 
79 in the female, and demonstrated the presence of gonococci in all. 
He also performed the following experiment: He utilized 3 women 
suffering from urethritis, but in whom the vaginal secretion was free 
from gonococci. He inoculated the vaginal discharge from these sub- 
jects into the urethras of 3 men. None of these contracted gonorrhea; 
later these, and a fourth individual, were exposed to the secretion from 
the urethra from the same women. Gonorrhea resulted in all. In 21 
confrontations, gonococci were found in both partners. Additional 
confirmatory proof of Neisser's discoveries was obtained by Cham- 
eron,^ Wyssokowich and Belleli,* the last named making his investi- 
gations in an examination bureau for prostitutes. In 1884 an im- 
portant series of experiments were conducted by Zweifel.^ The lochia 
from 6 normal cases, having first been found to be microscopically free 
from gonococci, was, with certain precautions, inoculated into the eyes 
of healthy infants. In none did ophthalmia neonatorum result. 
This observer therefore believed that only lochia containing gonococci 
could cause ophthalmia neonatorum. Ikinnn"' reported having con- 
stantly found gonococci in the lochia of mothers whose infants suffered 

' Kschbaum; Deut. mod. \\'och., Berlin, Manh, lS,s:j, p. 1S7. 
' Xewbcrry: Maryland McmI. Jour., 1SS2, vol. ix, p. 481. 
' Marchiafava: Gazz. dogli Ospod., ann. 3, Xo. 21. 
* Keysor: Maryland Med. .lour., 1SS2, vol. ix, p. 481. 
' .SternhiTR: Med. News, Phila., 1883, vol. xlii, pp. 07, 96. 
" Welandcr: Monats. f. prakt. Dermat., 1884, vol. iii, p. 12.5. 
' (Uiameron: Th&se de Paris, 1884, No. 346, pp. 3.5, 37. 
'Bellcli: Unione Med. Iviui.s., Alexandria. 18S4, 1, No. S. 
» Zweifel: Areli. f. Clyn., 1884, vol. xxii, p. 31S. 

'"Bumm: Dor Mikro-oruani.smus der Ronorrlioi.sehen SclileindiMUt-lJkrankiinKen, 
Gonoeoeeus Neisser, second edition, Wiesbaden, 1887. 


from ophthalmia neonatorum. Arning/ working in Neisser's cUnic, 
discovered gonococci in the pus from Bartholinian abscesses in 8 
cases of gonorrhea. Kammerer- claims to have found gonococci in 
the fluid of gonorrheal arthritis. Aubert^ found the gonococcus in 200 
cases of suspected gonorrhea, and believed that this organism was the 
most frequent cause of urethritis. Gama Pinto'* denied the specific 
character of the gonococcus, declaring that he found morphologically 
similar micrococci in the pus from various conditions. As the result of 
a study of 92 cases of ophthalmia neonatorum Kroner^ came to the 
conclusion that there were two forms of ophthalmia — one, caused by 
the gonococcus, and the other, the result of a bacterium. He also found 
gonococci present in the lochia from 18 out of 21 mothers, whose in- 
fants suffered from ophthalmia neonatorum. Paul published a paper 
proclaiming the virulence of the gonococcus. Icard'' (1884) describes 
cases of urethritis due to microorganisms other than gonococci. 
Sanger' stated, before the German Natural Science and Medical As- 
sociation of Magdeburg, in 1884, that the hope aroused by Neisser 
that the gonococcus would be the means of diagnosticating chronic 
gonorrhea had proved vain. He believed that it was an established 
fact that gonorrhea might exist without the presence of gonococci 
being demonstrable. He went further, and stated that, in view of the 
occurrence of non-pathogenic forms of diplococci, the presence of the 
gonococcus did not prove the gonorrheal nature of the disease. Fran- 
keP also believed that, as there were various forms of cocci in the geni- 
tal secretions of 'the female, culture and inoculation were the surest 
means of differentiating their clinical nature. Widmark^ examined 13 
cases of purulent ophthalmia, 12 in infants and 1 in an adult. In the 
secretion from 10 of these gonococci were found. In 2 cases of ure- 
thritis in young girls in which gonococci were demonstrated the parents 
had gonorrhea, and in the urethral secretion of both mothers gonococci 
were found. Oppenheimer^" studied the influence of various gonococ- 
cids upon pure cultures of gonococci. Lundstroem" (1885) examined 
the discharges of 50 cases of acute and chronic urethritis and found 
gonococci in all. Similar results were obtained by Kries (1885). 

' Arning, E.: Vierteljahressohr. f. Derm. u. Syph., 1884, vol. x. 

2 Kammerer: Cent. f. Chir., 1884, No. 4. ' Aubert: Lyon mc'nl., .Inly Ki, 1884. 
< Pinto: Med. Contemp., June 8 and 15, 1885. 

' Kroner: Amer. Jour. Bact., 1885, vol. viii, p. 197. 

Icard: Lyon m<^d., 1884, No. 81. ' Sanger: Arch. f. Gyn., 1884, vol. xxv, 1. 

« Frankel: Dcut. mcd. Wooh., 1885, No. 2. 

3 Widmark: Aich. f. Kinderheilk., 1885, No. 7. 
'° Oppenheimer: Aroh. f. Gyn., vol. xxv, No. 1. 

" Lundstroem: Studier Ofver Gonoc. (Neisser), Holsingfors, 1885; also Monats. f. 
prakt. Derm., 188.5, vol. iv, p. 4.55. 


Cseri/ of Budapest, reports that from 1883 to the date of the ap- 
pearance of his paper (1885), the discharge from 26 children suffering 
from contagious colpitis had been examined microscopically, and a 
large diplococcus, similar to Neisser's gonococcus, had been found 
in nearl}^ all cases. This discharge, when inoculated into the eye, 
produced an ophthalmia. The same writer relates the case of a near- 
sighted nurse who, while douching one of these children, accidentally 
introduced some of the vaginal discharge into her eye. An ophthalmia 
followed that resulted in the loss of the organ. Frankel- also found, 
in the vaginal discharge of children, diplococci which he described as 
identical with the gonococci of Neisser, and he believed these children 
to be free from gonorrhea. An excellent review of the French literature 
relating to the gonococcus was published by Martineau^ in 1885. He 
claims for Bouchard precedence by one year in the discover}^ of the 
gonococcus. His arguments are, however, unconvincing, and no 
proof is brought forward to substantiate the claim. During this year 
(1885) further confirmatory evidence regarding the virulence of the 
gonococcus appeared as the result of the work of Ferarri,^ Bouchard, 
De Pezzer,'' de Sinety and Henneguy.® In 1886 a number of observa- 
tions appeared showing that a purulent urethritis might occur as the 
result of micrococci other than -the gonococci. Thus, Bochart^ re- 
ports that in four years he has seen 15 such cases, basing his conclu- 
sions upon cultures and inoculations. Similar conclusions were ad- 
duced by Peterson,* Podres,'-' and C'revelli.'" 

During the next year Zeissl'' found a micrococcus resembling the 
gonococcus in the discharge from cases of non-gonorrhcal suppurating 
urethritis. Abelaender, Wendt, Giovannini,'- Lustgarten and Man- 
naberg" report finding a diplococcus in the normal urethra. These 
organisms were both intracellular and extracellular. All doubt as to 
the virulence and specificity of the gonococcus was finally set at rest 

f "seri, J.: Wicn. med. VVoch., 1885, No. 22 and 23. 

rrankel: Dout. mc.l. Wofh., 1SS.5, No. 2. 
' .Martineau: .Ann. Med. C'hir. Franc, et etrang., ISS."), vol. i, p. n; also La rliniq. sur 
la Hlciinor. choz la Fciiinif, 188.5. 

' Korarri: Gior. ili Med., 1885, vol. xxxiii, p. .337. 

' Dp Pezzer: Annal. des Mai. d. Org. Gen.-Urin., 188.5, vol. iii, p. 9.5. 

' de Sinety and Ilenneguy : Mfim. de la .soc. de Biol., August 8, 188.5, p. .5.53. 

Boehart: Monats. f. prakt. Dcrmat., 188(5, vol. v, p. 134. 

I'etcrson: St. Pctorsl)urn Dcul. rued. Zeit., 188.5, vol. vi, p. .517. 

' I'odre.s: Vierteljalirossohr. f. Dcrmat., Vienna, 188.5, p. .5.57. 

'° Oevelli: Th6se do Pari.s, 188(i; Australian Med. .lour., 1888, p. 89. 

", von: Comp. d. Path. u. Therap. d. prim. .Svph. u. einf. vener. Krank., \'icnna, 
18.50. I 1 .1 

" Giovannini: Gaz. dcgli Ospcd., Milan, 188(i, .No. 01. 

" I.uslgarlcn ami Mann:it)erg: ViertcljahrcssiOir. f. Dermal. M. Sypli., 1S,S7, p. 90.5. 


by the appearance of Bumm's^ masterly paper, in which he adduced 
abundant material and incontrovertible proof of the verity of his 
conclusions. In a paper published in 1888 Schnurmans-Stekhoven^ 
questions Bumm's results, and expresses doubt as to the existence of a 
specific micrococcus of gonorrhea. He bases his attack on the ground 
that Bumm had not proved that the cultures used by him were pure. 
Papers tending to prove that a urethritis might be produced by a 
number of micrococci other than the gonococcus were pubUshed by 
Rauzier,^ Pouey,"* and Legrain-^ during 1888. 

In the following year Steinschneider and Galewsky'^ isolated from 
four normal urethras a diplococcus morphologically analogous to the 

Rovsing^ (1890) reported finding the Diplococcus urese non-pyo- 
genes in the discharge from the normal female urethra. As might 
have been suspected, the fincUng, by so many trustworthy investiga- 
tors, of diplococci morphologically similar to the gonococcus in dis- 
charges from undoubtedly normal urethras created much confusion. 
Fortunately, in the next year (1891) Wertheim's method of preparing 
cultures of the gonococcus permitted so many positive inoculations to 
be made as to close forever the discussion as to the pathogenic character 
of the gonococcus. 

No historic sketch on gonorrhea, however brief, would be complete 
without a reference to the wonderful skill and genius of Lawson Tait, 
who performed much of the pioneer work in the surgery of pelvic 
inflammatory disease. He recognized the tubal origin of these cases, 
and the results of the "Tait operation," as salpingo-oophorectomy 
for adnexitis was called, were so brilliant as to attract general attention 
throughout the entire surgical world. 


Aegineta: The Sydenham Society, London, 1S44, P- 594. 
Andri: De la Gener. d. vers, dans le corps d I'homme, Paris, 1700. 
Bokai: Allgemeine Med. Central-Zeitunp. 1880, No. 74. 
Bostock and Riley: Natural History of Pliny, 1856. 
Bumm: Arch. f. Gyn., 1884, vol. xxiii, p. 327. 

'Bumm: Beitriige z. Kennt. d. Gonococcus, Wiesbaden, 1885; also Der Mikro- 
organismus d. gonorrhoischen Schleimhaut-Erkrankungen, Gonococcus Neisser, second 
edition, Wiesbaden, J. F. Bergmann, 1887. 

2 Sehnurmans-Stekhoven: Deut. med. Woch., 1888, No. 35, p. 717. 

' Rauzier: Gaz. Hebd. d. Soc. Med. d. Montpellier, February, 1888. 

* Pouey: These de Paris, 1888, No. 262. 

'Legrain: These de Nancv, 1889; also Annal. des Mai. d. Org. Gen.-Urin., 1888, p. 
523, etc. 

'Steinschneider and Galewsky: Verb. d. Deut. Dermat. Gesell., Vienna, 1889, vol. i, 
p. 159. 

' Rovsing: Die Blasenentziindung, etc., Berlin, 1890. 


Castex: Jour. d. Connais. Med., 1SS7, vol. cxl\'iii, p. 183. 

Cockburn: The Symptoms, Nature, Cause, and Cure of Gonorrhea, London, 1715. 

De Amicis: Riv. Chn. e Therap., March 11, 1884. 

Finger, E.: Blennor. d. Sexual-Organs, 1905, p. 14; Blennorrhea of the Sexual Organs, etc., 

in Wood's Med. and Surg. Monograplis, vol. ii, p. 33. 
Findley, P. : Gonorrhea in Women, St. Louis, 190S. 
Galen: De Loc. ASec., 2, 8, edit. Ruhn, vol. iii, p. 91. 
Haeser: Lehrbuch, vol. i, p. 751. 
Herodotus: History, vol. i, p. 105. 
Holmes: System of Surgery. 

Jou.sseaume: Des Veget. Para.sit. d. I'homme, Paris, 1862, p. 130. 
Judd; On Venereal and Urethral Diseases, London, 1836, p. 2. 
I\joner: Arch. f. Gyn., 1884, vol. xxv. 
Marcellus: De Med. Empir. Phjsic, Basel, 1536, fol. 
McKay: Ancient Gynecology, London, 1901. 
Morrow: N. Y. Med. Jour., 1881, vol. x.xxiv, p. 271. 
Neisser: Wiesbaden, 1887; Trans, of the Cong, of Ger. Naturalists and Phys. at Strass- 

burg, 1885; abstract in Centralbl. f. d. med. Wissenschaften, 1886, No. 32. 
Preuss: BibUsch-Talmudisehe Medizin, 1911, p. 409. 
Salter: Hirschberg u. Lebert, Sitzungsber. ti. d. dreizehn. Versanim. d. ophthal. Gesell., 

Heidelberg, 1881, p. 18. 
Sanger: Verhandlung. der deutschen Gesellschaft ftir Gynakologie, Leipzig, 1886. 
Spooner, H. G. : Amer. Jour. Dermatology, 1909, vol. xiii, No. 4, p. 195; Post-Graduate, 

1905, p. 950. 
Tait, Lawson: Diseases of Women, London and Edinbtu-gh, 1877., F.: Th^se d. Nancy. 1880; pub. in Annales de Dermat., 1881. 

Widmark: Hvgiea, September, 1884; also Monats. f. prakt. Dermat., 1885, vol. xiv, p. 64. 
Wise, T. A.: Hindu Syst. of Med., London, 1860. 


The gonococcus, discovered by Neisser in 1879, is the specific 
cause of gonorrhea. So conclusively has this been proved, that where- 
ever this micrococcus is found, a positive diagnosis can be made. In 
the chronic, or so-called latent, cases, especially in the female, it is 
sometimes extremely difficult to demonstrate the gonococcus, and for 
this reason negative bacteriologic results, unless frequently repeated 
and performed under favorable circumstances, cannot positively ex- 
clude the gonorrheal nature of the disease. 

It has been shown that the gonococcus is not a single organism, but 
a group of organisms. This accounts for the fact that autogenous 
vaccines have proved most successful, and that polyvalent serum is 
superior to that prepared from a single strain of gonococci. This fact 
also explains, to a certain extent, the difference in severity that occurs 
in different cases of gonorrhea. In another place references have been 
quoted that tend to show that certain strains of gonococci are more 
prone than are others to produce septicemic or metastatic manifesta- 
tions of the disease. 

Morphology. — The gonococcus is a coffee-bean-shaped organism; 
it occiu's most frequently in pairs, sometimes in tetrads, and more 
rarely in groups of 8. The flat, or sometimes slightly concave, sides 
of the organism are approximated, a narrow space being visible be- 
tween the halves of the cocci. The organism is frequently spoken of 
as being kidney, D-, or biscuit-shaped, the Germans likening its form 
to that of their "Semmel." Unstained, and examined with a low 
power, the gonococcus appears as a round or slightly elongated organ- 
ism, about 1.25/x in length by 0.7 ^u in breadth, the double nature of 
which cannot be distinguished. 

Owing to their method of fission, the grouping of the gonococci is 
characteristic. The older cocci lengthen out, become constricted in 
the middle, and finally divide, to form a new pair, the division taking 
place at a right angle to the median fissure, so that one diplococcus 
develops two double pairs. At first the young organisms are spheric, 
but as they grow older, the inner surfaces become flattened or slightly 
concave. As a result of this method of multiplication the gonococci 



in film specimens are seen to occur in a discrete group or clump, never 
in a chain. The number of cocci in each group is usually divisible by 4. 
Perhaps 20 or more gonococci may be observed somewhat closely 
packed together, whereas the remainder of the field will be entirely 
free from these microorganisms. Near the center of the group the 
cocci are usually more closely aggregated than toward the periphery. 
This grouping is similar to the pattern made by a closely choked shot- 
gun. The gonococci are found both intracellularly and extracellu- 
larh', but are never seen within the nucleus. The intracellular location 
is the more characteristic. This intracellular qualitj' of the gonococcus 
doubtless, to a certain extent, accounts for the peculiar chronicity of 
the disease, as intracellular microorganisms are necessarily less sus- 
ceptible to the action of germicides than are those that lie free in the 

Dimensions of the Gonococci. — The diameter of the associated 
pair of cocci varies, with the stage of their development, from 0.8 fi to 
1.6 M in the long d'ameter, by 0.6 m to 0.8 ix in the short diameter, the 
average being about 1.25 m in the long diameter by 0.7 n in the short. 
There are undoubtedly many strains of gono- 
cocci, and these vary somewhat in size, just a* j* tl fiS ** S 
as individuals of the .same strain do in dif- • 99 mm mm «« «« 
ferent generations, when grown upon artificial 

1- Fig. I. — Method of Rkduplica- 

meClia. tion- of the Goxococti. 

Motility. — The gonococcus is generally be- 
lieved to bo non-motile, although J. Eisenberg credits tlio organism 
with a rotary or oscillatory movement. It is certain, howevcn-, that 
the gonococcus is not autolocomotive. 

The Relation of the Number and Morphology of the Gonococci to 
the Stage and Virulence of the Disease. -The first discharge, th(> result 
of a gonorrheal infection, is made up of mucus, epithelial cells, red 
blood-corpuscles, and debris. In this the gonococci are found in vary- 
ing numbers, fre(4uenlly (|iiilc ;il)undantly. The majority of organ- 
isms are free in the serum, but they may be agglutinated ui)on or 
found within the epithelial cells. P'or diagnostic purposes it is im- 
portant to demonstrate the intracellular micnxirganisins. This is 
sometimes (luite difficult, as at tiiis stage intracellular gonococci are 
comparatively rare. When a group of diplococci are found on a cell, 
individual organisms may, as a rule, be seen overlapping the cell 
edges, whereas when the gonococci are actually within the cell, this 
la not the The difTerent planes that can be demonstrated iiy 
focusing will also usually dear up this point. At this stage the gono- 
cocci arc nearly all of the well-known cofTee-i)can shape. As llic (iise!is(> 


develops and the discharge becomes mucopurulent, the number of 
gonococci increases quite markedly, and the proportion of intracellular 
cocci becomes much greater. During the height of the inflammation 
all the cellular constituents of the discharge diminish in proportion to 
the pus-cells, which now dominate the field. On account of the great 
number of pus-corpuscles, the number of the gonococci appears to be 
diminished. This, however, is not the case. At this stage nearly all 
the gonococci are intracellular — indeed, some authorities maintain 
that all the extracellular gonococci that are found are the result of 
trauma in preparing the film, and are caused bj^ the freeing of the origi- 
nal intracellular organism during attempts to make a very thin film of 
the preparation. That this is not the case we have demonstrated a 
number of times in films that have been prepared without inflicting 
any trauma whatever. Large numbers of gonococci are sometimes 
found within a single epithelial cell or pus-corpuscle. As many as one 
hundred have been counted, and although these cells sometimes appear 
as if ready to burst, as a general rule they present remarkably little 
evidence of injury. Discussion is still rife as to whether the gonococci 
actually invade the pus-cell or are taken up by them as the result of 
phagocytic action. The former seems the more probable theory, as 
there is no evidence to prove that the gonococci are destroyed by the 
pus-corpuscle, whereas, on the contrary, it is easy to demonstrate that 
they multiply readily within the cell. Moreover, the fact that they 
are found within epithelial cells that have no phagocytic action what- 
ever strengthens .this view. According to Bumm,' the invasion of the 
epithelial cells and leukocytes is due to a vital activity on the part of 
the microorganisms. Large numbers are sometimes present. Scholtz,- 
Pollock and Harrison,^ and others believe that intracellular gonococci 
are the result of phagocytosis, and that this process occurs in the free 
secretion and not in the depths of the tissue, and state that if the 
surface discharge be wiped off and exudate expressed from the depths 
of the tissue, extracellular organisms are chiefly found. 

During the terminal stage the number of gonococci and pus-cells is 
diminished. Guiteras^ states that at this time the pus-cells frequently 
contain fat-granules and show other signs of disiritegration. As a 
rule, in chronic cases, when pus-cells are numerous in the discharge, 
gonococci can be demonstrated without difficulty, but when pus-cells 

' Bumm, E.: Der Mikro-organismus gonorrhuischen Schlcimhaut-Erkrankungen, 
Wiesbaden, 1885. 

^Scholtz: Arch. f. Dermat., 1899. 

' Pollock, C. E., and Harrison, L. W.: Gonococcal Infections, London, 1912, p. 63. 

' Guiteras, R. : Urology, D. Appleton & Co., New York and London, 1912, vol. ii, 
p. 3.58. 


are scanty, the gonococci are few in number. Large numbers of 
coarse-grained eosinophile cells are generally present about the third 
or fourth week of the discharge. During the chronic stage pus-cells 
diminish in number, epithelial elements become more numerous, and 
the gonococci are lessened in number. In the secretion from the ure- 
thra at this stage the so-called "clap shreds" are present. These con- 
sist mainly of transient epithelium, mononuclear leukocytes, a few 
gonococci, and pus-corpuscles. With the diminution in the amount of 
pus a relatively greater number of extracellular gonococci are found. 
During the chronic or terminal period involution forms of gonococci 
are sometimes encountered. These are often granular in appearance, 
round or irregular in shape, and have varjdng staining properties. 
Wynn' states that the more active the lesion, the greater are the 
nimiber of extracellular gonococci present. 

Thus we see that the microscope furnishes a very important means 
not only of diagnosing gonorrhea, but of differentiating between the 
various stages of the disease. Harmsen- and Sireday and Bigart' 
have demonstrated the value of the microscope in this connection. 

It has been asserted that the number of gonococci in the secretion 
in a given Case, the previous historj^ of which is known, may be taken 
as a guide as to the probable course and virulence of the infection. 
This theory is doubtful, for the gonococci are at no time equally dis- 
tributed throughout the discharge, and to be of any value whatever, a 
large number of preparations must be examined. The prolonged con- 
tinuance of large amounts of pus- and of numerous gonococci in the 
secretion is, however, certainly an evidence of the chronicity of the 
period of active inflammation. However, clinical manifestations are 
usually sufficient, at this time, to demonstrate such a condition. 

During the stage of active inflammation there is usually no difficulty 
in demonstrating the gonococci in smear preparations, provided these 
are properly i)repared. Later, however, during the chronic period, 
this is, unfortunately, far from being the case. At this time gonococci 
are often found only after a most thorough search. This is true in the 
male, but is more especially noticeable in the female. A knowledge 
of how, when, and from where to obtain the secretion to be examined 
during this stage of the disease is of great aid in clearing up a doubtful 
diagnosis. In the female, film preparations should be made from the 
discharge obtained from the cervix, urethra, vulvovaginal glands, and 
the vagina, althougli that from the latter is of little value compared to 

' Wyiiri; Liiiiccl, I'.ll).'), vol. i, No. (i, p. :i.5J. 

' Hiirmscn: Zcit. f. Hy(;. u. Infektions-Krankh., 1900, vol. liii, p. 89. 

^ Sireday ami Bigarl: .\iiiial. do (Jyii. et d'Olwt., Docembor, 1905. 


that obtained from the other structures named. The times when gono- 
cocci are most likely to be found are immediately after the menstrual 
periods and during the first few days following labor, miscarriage, or 
abortion, when the lochia is beginning to diminish. It should be 
remembered that excesses of all kinds, paid at the shrine either of 
Venus or of Bacchus, are likely temporarily to light up a chronic or 
latent gonorrhea, and as a consequence gonococci will more readily 
be found immediately following such periods. Wlien examining pa- 
tients during periods when gonococci are not likely to be numerous, 
the passage of a catheter a short distance into the urethra or a slight 
dilatation of the lower cervical canal will set up a mild traumatic irri- 
tation in the discharge, from which the organism can often be easily 
demonstrated, or the suspected area may be touched with a solid 
stick of silver nitrate, and in the exudate from the irritation thus pro- 
duced the organism may be found. If cultures are to be taken, care 
must be observed that all the silver has disappeared; this is usually 
the case at the expiration of twenty-four hours. The alcohol test is a 
favorite one with many genito-urinary specialists, and consists in 
having the patient drink a few glasses of beer, champagne, or Burgundy 
for a few days prior to the examination, and a few pickles added to the 
diet are recommended by some authorities. In the mean time all 
treatment is suspended. Similar means may be employed as a test 
for cure, and should be repeated with negative results at least three 
times before a clean bill of health is given. 

The "beer test" is of less value in the female than in the male, as 
its efficacy depends largely upon producing an irritating urine. As 
urethritis in women is usually of secondary importance to the cervical 
infection, the benefit to be derived from this test under such circum- 
stances is somewhat iiinited. Van de Velde' and others state that a 
diagnostic vaccination often produces an increased secretion in which 
gonococci are more numerous, and are often thus easily found when 
they could not previously be demonstrated. When obtaining the 
secretion from the urethra, the material should be expressed by firm 
milking movements, as in this way the discharge is obtained from the 
deeper crypts and glands, and contamination from other bacteria 
usually present about the meatus is avoided; besides, the secretion is 
secured from the most recent and freshly inflamed parts. This dis- 
charge will be found to contain more gonococci than that secured from 
the surface, from which point the inflammation has probably passed 
its acme at the time of examination. For the same reasons, in making 
films from the cervical secretion, the material should be obtained from 

1 Van de Velde: Monats. f. Geb. u. Gyn., April, 1912. 


a point well within the cervical canal, after having first compressed 
this organ. Frequently a slight irritation, either chemical or trau- 
matic, will be sufficient to set up a mild local irritation, in the discharge 
from which gonococci can readily be demonstrated after a failure to 
demonstrate them by ordinary means. In such an event the secre- 
tion for examination should not be taken until twenty-four hours 
afterward, and this is particularly true if the irritation has been pro- 
duced bj^ an antiseptic, such as a strong solution of silver, which is 
often used for this purpose. Gonococci are usually absent, or present 
only in diminished numbers, immediately after treatment by anti- 
septics. ^^'henever practicable, it is best to secure the suspected 
secretion early in the morning. At this time the urethral canal has 
probably not been washed out so recently by the passage of urine, and, 
besides, as Finger has pointed out, more excretion is formed at night. 
This is not so true of patients who are bedfast. In chronic or latent 
cases it should alwaj's be borne in mind that the gonococci are present 
only in small numbers, and that the amount of secretion examined on a 
given slide is comparatively infinitesimal; for this reason a number of 
preparations — at least three or four — should be made from the secre- 
tion of each suspected locality, and such examinations, if negative, 
should be repeated on two or three successive days. A movable stage 
is a great aid in examining such preparations, for by its use the entire 
slide may be inspected s^'stematically. In those chronic cases in which 
it is impossible to demonstrate the gonococci by staining methods, and 
in which the clinical manifestations point toward a Neisserian infec- 
tion, or when the medicolegal aspect of the case is involved, cultures 
should be made. These, because of the difficulty attending the 
growth of the gonococci on artificial media, are of value only when 
performed by a skilled bacteriologist. 

Staining Properties of the Gonococcus. — The gonococci stain 
readily with any of the anilin dyes. In order satisfactorily to demon- 
strate the organism, the point to be desired is to stain the gonococci 
somewhat deeply and the surrounding structures as little as possible, 
so that the bacteria will stand out prominently. For this reason, 
whatever stain is selected, care should be taken not to overstain the 
preparation. For staining film preparations, a great number of 
methods are in use. Any of the basic anilin dj^es, if projierly diluted, 
will give good results. For demonstrating the presence of gonococci 
in pus, I.oflicr's' solution of methjdene-blue is one of the best, for while 
staining the gonococci deeply, it leaves the cell cytoplasm but faintly 
colored. Methyl-violet, gentian-violet, Bismarck-brown, safranin, 

' LofUtT ami Lcistikiiw: C'h:iiit('-Aiiiuil('ii, Jahrgang 7. 


malachite-green, or fuchsin may also be employed. These last are 
perhaps superior to methylene-blue when the suspected material is 
free from or contains but little pus. The specimen may be either air 
dried and fixed by being passed through the flame, or may be air dried 
and then fixed by placing the films in a solution of equal parts of abso- 
lute alcohol and ether for fifteen minutes. The former method is the 
quickest ; the latter gives more beautiful preparations. The following 
is an excellent simple stain when pus is present in the discharge: 

Loffler's Methylene-blue Solution for Staining Gonococci 
(a) Spread pus evenly over the cover-glass. 
(6) Air dry. 

(c) Fix either by passing through flame three times or by placing in equal 
parts of ether and absolute alcohol for fifteen minutes. 

(d) Cover smear with a solution of methylene-blue (saturated 95 per 
cent, alcoholic solution of methylene-blue, 30 c.c; to a solution of potassium 
hydroxid in water, 1:10,000, 100 c.c.) for two minutes. 

(e) Wash in tap-water. 

(/) Dry with buff photo blotting-paper. 
{g) Mount in xylol balsam. 

Result: Gonococci stain deep blue; nuclei, a lighter blue; and proto- 
plasm, pale blue. 

If speed is desired, the method advocated by Bumm may be 
adopted. This consists of substituting for the methylene-blue a 
concentrated watery solution of fuchsin, this stain requiring only 
thirty seconds. The preparation may be examined without a cover- 
glass. A 2 per cent, alcoholic solution of methyl-violet solution may 
also be employed. This is practically a differential stain, and may be 
used very rapidly. It gives excellent results. Some authorities 
prefer to examine the suspected secretion by drying it on the slide 
without fixing. It is then stained and examined while still damp. It 
is claimed for this method that by it the gonococci are larger and more 
readily detected. In cases in which difficulty is encountered in demon- 
strating the gonococci, or for class demonstration, one of the double 
stains is often of value. These also make beautiful preparations. 

Neisser's method of double-staining gonococci is as follows: 

Neisser's Method of Double Staining Gonococci in Smear Prepara- 

(o) Place the fixed specimen in a concentrated alcohohc solution of 
eosin and heat gently for three minutes. 

(6) Drain off eosin, wash in tap-water, and place immediately in a satu- 
rated 95 per cent, solution of methyl-blue for forty-five seconds. 


(c) Wash in tap-water. 

(rf) Dry with the aid of buff photo blotting-paper. 

(e) Mount in xj-lol balsam. 

Result: Gonococci and cell nuclei stain blue; protoplasm, a dull red. 

F. Abbott recommends the following double stain: 

Abbott's Staining IMethod 

(a) Spread, dry, and fix in the usual manner. 

(b) Treat ^\ith 20 per cent, solution of tannic acid for one or two minutes. 

(c) Wash in alcohol. 

(d) Dry ^ith filter-paper. 

(e) Stain with Ziehl's solution of fuchsin. 

(f) Decolorize in acid alcohol (acetic acid, 1 part; alcohol, 100 parts; 
or hydrochloric acid, 1 part; alcohol, 500 parts). 

ig) Dry. 

(h) Stain with meth3-l-green. 

(0 Wash in water. 

(i) Mount. 

Result: Gonococci are dark red; nuclei, purple; protoplasm, light green. 

Another double stain is as follows: 

(a) Prepare and fix films in the usual manner. 

(6) Stain for thirty seconds in a freshly made mixture of Lofller's methy- 
lene-blue (30 c.c. of saturated alcoholic solution of methylene-blue to which 
100 c.c. of 0.01 per cent, of caustic potash (1 c.c. of 1 per cent, caustic potash to 
100 c.c. of water) has been added. This solution keeps M^ell), 30 parts, 
saturated alcoholic solution of eosin, 10 parts. 

(f) Wash and mount in the usual manner. 

Result: Bacteria and cell nuclei blue; the remainder, red. 

Pappexheim's Stain 

(a) Prepare, dry, and fix in the usual manner. 

(6) Stain for four minutes in methyl-green, 0.15 gram; pyronin, 0.25 
gram; alcohol, 2.5 c.c; glycerin, 20 c.c; phenol in water (2 per cent, solution). 
100 cc 

(c) Wash in water. 

((/) Dry with blotting-i)aper. 

(e) Mount in the usual manner. 

Result: The gonococci arc red and t!ie cell nuclei are blue. 

A simple ni(!thod of applying I'appenhcini's stain, and one giving 
ahnost as reliable results, is as follows: 

(n) Prepare, dry, and fix in the usual manner. 

(/>) Stain for one minute in the following solution: To 5 c.c. of distilled 

No. 2: 


water add methylene-green, about twdce as much as can be placed on the end 
of the blade of a pen-knife, and one-fourth this amount of pyronin (Grtibler, 
Leipzig). This solution should be of a blue-violet color. 

(c) Wash in water. 

(d) Mount in the usual manner. 
Result: Gonoeocci are red; nuclei, blue. 

One of the best of the counterstains is that recommended by Sax,' 
and known as the modified Romanowsky- stain. With this method 
the smears require no previous fixation, as the methyl-alcohol accom- 
plishes this while the staining is going on. For this reason the un- 
diluted stain is first poured on the slide. Then, in order to differen- 
tiate, distilled water is added as described below. Two solutions are 
used, which should be kept in separate well-stoppered bottles. They 
consist of: 

No. 1: 

Aqueous eosin ("W. G." Grtibler) 1 part 

Methyl-alcohol, chemically pure, absolute. . . . 100 parts 

Methylene-blue (pure, medicinal) (Grtibler) . . 1 part 
Methyl-alcohol, chemically pure, absolute. . . . 100 parts 

Equal parts of No. 1 and of No. 2 are mixed and poured on the 
slide, where they should be allowed to remain not longer than one 
minute. Distilled water is then added to the dye until about four 
times the amount of the original fluid is on the smear. This remains 
on the slide for five minutes, and is then washed off with distilled water 
and the slide dried and examined. The resulting smear shows the 
nuclear material and bacteria blue, and the background salmon col- 
ored, with dark-pink cell-bodies. Or the following method may be 
employed : 

Romanowsky's Stain (Leishman's Modification) 
Dissolve one "Soloid" product of Romanowsky's stain (Leishman's pow- 
der), 0.015 gram, in 10 c.c. of pure methyl-alcohol. Allow this solution to 
stand for about three or four hours before using. Spread j3us evenly over the 
cover-glass and allow same to dry in the air. Without fixing the specimen 
drop enough of the prepared stain on it completely to cover the smear. Allow 
the stain to act for from fifteen to thirty seconds, and then add as many drops 
of distilled water as were used of the stain. The diluted stain should remain on 

' Sax: Trans. Araer. Urol. Assoc, 1909, Brookline, 1910, vol. iii, p. 131. 
'Romanowsky, D. : St. Petersburg, med. Wochenschr., 1891, No. 34, p. 297. 


the slide for from five to ten minutes, after which time it is washed off with 
tap-water and the slide dried with blotting-paper. Mount in xj-lol balsam. 
Result: Cocci stain blue; nuclei of leukocj'tes, rose-red; eosinophile 
granules, red; protoplasm of mononuclear and coarsely grained eosinophile 
cells, light blue. 

McKee' recommends that the films be prepared after the method 
used in trachoma cases. The material is spread on the slide, dried in 
the air, fixed for ten minutes in 80 per cent, alcohol, stained with 
Giemsa's solution, 1, to 20 parts of distilled water, for twenty minutes. 
Or Giemsa's new method may be employed. This is as follows: Dry 
the film in the air, fix in 80 per cent, alcohol for ten minutes, place 
film in a Petri chsh, and cover with staining fluid consisting of equal 
parts of Giemsa stain and pure methyl-alcohol. Stain thus for thirty 
seconds, then add 10 or 15 c.c. of cUstilled water, and agitate until the 
mixture becomes homogeneous. In three minutes remove and pro- 
ceed to mount the specimen in the ordinary manner. McKee states 
that by either of these stains gonococci may be demonstrated in epi- 
thelium when ordinary methods fail. 

Leszczynsky's Stain^ 
The smear is prepared and fixed in the usual way. 

Stain for one or two minutes or until smear is deep liiuc, in tlio following 

Saturated watery solution of thionin-bhic 10.0 

Phenol (pure) 2.0 

Distilled water 88.0 

Wash in distilled water and stain for forty-five seconds to one minute, or 
until a clear yellow, in: 

Saturated watery .solution of picric acid / ^ , 

Solution of potassium hydroxid (0.1 per cent.) .. 1 

Wash with distilled water, dry with blotting-paper, immerse in absolute 
alcohol for five seconds, wash again with distilled water, dry with blotting- 
paper, and mount in xylol balsam. 

Result: Intracellular but not extracellular cocci stain black. 

Knaack's MKTHon OK Staining Gonococci in Smear Puepakations 

(«) Prc])are in ordinary manner, air dry, ami fix. 

(h) Stain in a saturatrd !).") piT cent. a!coii(ilic solution of nietli.\lcne-bhie 
for three miiuites. 

(c) W'lisU in tap-water and tlry with buff i)hoto lilotting-jiapcr. 

' M(K<c, II.: Tlic()|)litli:ilmir, .January. l!)l-_', p. I. 

■ I'oll(»k, C. i;., and ll.inisdii, I.. \V.: Coriococcal Iiifoclums,, I'.MJ, p. •JIC. 


(d) Place in a 1 per cent, solution of argonin and distilled water for four 

(e) Wash in distilled water. 

(/) Place in a watery solution of fuchsin (saturated) for ten seconds. 
Ig) Wash in tap-water, dry with blotting-paper, and mount in xylol 

Result: Gonococci stain blue; protoplasm, pale pink; nuclei, purple. 

Lanz's Stain^ 
Saturated solution of thionin-blue in 2 per cent. 

phenol 4.0 parts; to 

Saturated solution of fuchsin in 2 per cent, phenol 1.0 part 

Mix solution immediately before use and allow the stain to act for from 
fifteen to thirty seconds, wash in distilled water, dry with blotting-paper, and 
mount in xylol balsam. 

Result: Cocci stain blue; nuclei of cells, bluish red; and their proto- 
plasm, hght red. 

Methyl-green-pyronin Stain (Unna-Pappenheim) for Gonococci in 


Methyl-green (00 crystals (Griibler) ) 0.15 gram 

Pyronin 0-50 

96 per cent, alcohol 5.00 c.c. 

Glycerin 20.00 " 

Warm the solution and stain the sections for four or five minutes in the 
incubator; wash in cold distilled water. Dehydrate quickly in absolute 
alcohol, clear in xylol, and mount in xylol balsam. 
Result: Gonococci stain red; cell nuclei, blue. 

Staining by the foregoing methods, while it brings out the gonococci, 
also colors other organisms. Only rarely are other bacteria morpho- 
logically similar to the gonococci present in the male urethra. The 
same cannot be said for the female genital tract, which, especially in 
the multipara, literally swarms with organisms, some of which, stained 
by the methods just described, are indistinguishable from the gono- 

It is to Dr. Gabriel Roux,= of Paris, that we are indebted for the 
discovery of a means that practically difTerentiates, by a rapid stain- 
ing method, the gonococcus from all other morphologically similar 
organisms found in the genital tract. The method referred to is the 
staining of suspected material by Gram's solution. In 1886 Roux 
published his conclusions. His findings were confirmed in the follow- 
ing year by Allen' and Wendt,'* of New York, whose papers, although 

'Pollock, C. E., and Harrison, L. W.: Gonococcal Infections, London, 1912, p. 216. 
2 Roux, G.: Le Concours Medical, November 13, 1886; also Report Acad, des Scien.j 
Paris, November 8, 1886. 

= Allen, C. W.: Jour. Cutan. and Genito-urin. Dis., N. Y., 1837, vol. v, p. 81. 
< Wendt, C. E.: Med. News, Phila., 1887, vol. 1, p. 455. 


appearing separately, are practicallj' identical in so far as results are 

Gonococci are decolorized by Gram's stain, and in this they differ 
from the majority of other bacteria found in the genitalia, with which 
they are likely to be confused. 

In cases in which the diagnosis is of great importance, or to secure 
medicolegal evidence, this method is not sufficient, and cultures must 
be resorted to. Gram's method is also uncertain when "clap shreds" 
are present. In chronic cases gonococci may occasionally stain ir- 
regularh^ by Gram's method, or be themselves atjqjical in shape. 
Gram's method of staining is as follows: 

Gram's Staining Method 

(a) Prepare, dry, and fix the secretion in the usual manner. 

(b) Stain in anilin-water-gentian-violet or anilin-water-methyl-blue for at 
least two minutes. (This solution may be made as follows: Place sufficient 
anilin water in a test-tube to cover the bottom. Then fiJl the tube three- 
fourths full with distilled water. Shake well. After shaking, undissolved 
oil should be present. Filter through moist filter-paper. The filtrate must 
be clear. If any oil-droplets have passed through, refilter. To this clear 
solution of anilin oil add a saturated solution of gentian-violet or methyl- 
violet until a shining film appears on the surface, or as much dye as will dis- 
solve may be added. The staining properties of this mixture may be in- 
creased by adding 1 e.c. of a 1 per cent, solution of sodium hj'droxid to 100 c.c. 
of the mixture. These stains do not keep well, nor does anilin-watcr, and 
therefore should be freshly prepared.) 

(c) Wash in anilin-water. 

{d) Stain in Gram's solution for from thirtj' seconds to two minutes, ac- 
cording to the thickness of tlie film, etc. (Gram's solution consists of 1 part 
of iodin; 2 parts of potassium iodid, and 300 parts of distilled water. It is 
best to dissolve the iodin and potassium iodid in 5 parts of water and then add 
this to the remaining 29.5 i)arts of water.) 

(e) Decolorize the preparation in absolute alcoiiol until no more color is 
given off. (It is best to use two or three alcohols.) At this stage Gram's 
positive bacteria are stained blue black, while Gram's negative organisms 
are unstained. The cover-glass, therefore, can now be examined in water 
or may be dried and mounted in balsam or may be — 

(/) CounttTstaincd with a watery snhition of fuchsiii, tliiity seconds to 
one minute, and then — 

(g) Washed in water. 

{h) Mounted in the usual mamiiT. 

(iram's method may also be applied as follows: To 10 c.c. of dis- 
tilled water add 2 e.c. of anilin oil. Sliake, and filter- tlirdugh moist 


filter-paper to remove oil-globules. To the clear filtrate add 1 c.c. of 
98 per cent, alcohol and a like amount of a concentrated alcoholic 
gentian-violet solution. After fixing the suspected secretion by pass- 
ing it through the flame in the usual manner it is covered with this 
solution for from two to three ininutes. Drain off excess of stain with 
filter-paper (do not wash in alcohol) . The cover-glass is now placed in 
Gram's solution for five minutes, and thence transferred to absolute 
alcohol to decolorize. This should be continued until the drainings 
fail to stain the filter-paper. After the alcohol the preparation is 
washed in water and placed in a solution of Bismarck brown, 1 part, 
and water, 5 parts. In this it is allowed to remain for one or two min- 
utes, or for forty-five seconds in a saturated aqueous solution of Bis- 
marck brown diluted with three times its volume of water. It is then 
washed in water and mounted in the usual way. The gonococci, 
having been decolorized by the Gram stain, are now bi'own. 

Gram's Method for Sections 

(a) Stain with anilin-water-gentian-violet or anilin-water-methyl-blue 
or from ten to twenty-five minutes. 

(6) Wash in anilin-water thirty seconds. 

(c) Transfer to Gram's solution for one to two minutes. (Sections now 
become brown.) 

(rf) Wash in .absolute alcohol until section appears nearly or entirely 
unstained. The purple color of the gentian-violet changes to dirty yellowish 
brown, and the section resembles tea-leaves. Section must become brown. 
In the alcohol the purple color of the gentian-violet returns and is dissolved 
out, so that if the manipulations have been properly performed, the films at 
this stage are practically colorless. The decoloration may be hastened by 
moving the section gently about in the alcohol. Two or three baths are 
usually required — a fresh one as soon as the first becomes discolored. If 
drop glasses are used for decolorizing, it is important to remember the side of 
the slide on which the section is, for this is somewhat difficult to determine 
after decolorization has taken place. At this stage the section may be cleared 
in cedar oil and mounted; Gram's positive organisms are blue black, and 
Gram's negative bacteria are unstained, or the section may be counterstained 
to bring out the tissue and micrococci that are not stained by Gram's solution. 

(e) For countcrstaining, wash in water and immerse in a solution of 
dilute fuchsin for from five to ten minutes. If desired, a solution of eosin may 
be substituted for the fuchsin for fifteen or thirty seconds. 

(/) Wash in 60 per cent alcohol. 

(g) Dehydrate in absolute alcohol. 

{h) Clear in cedar oil or xylol and mount. 

Result: All the Gram-positive bacteria are stained blue black; the tissue, 
red; the cell nuclei, pale blue or even dark blue. Bacteria are frequently not 


stained equally well in all parts of the section, and this is particularly likely 
to be so if the section is a large one or thicker than 5 ix. 

Gram's method, modified as follows, has the advantage that the 
stain in the preparation keeps much better. Instead of making up the 
stain with anilin-water, a 0.5 per cent, solution of carbol-water is sub- 
stituted. After staining, the preparation should be washed in carbol- 
water of a corresponding strength. The addition of one-tenth part 
of a solution of methylene-blue is recommended for decolorizing. 
For decolorizing quickly Gunther prefers absolute alcohol to which is 
added sufficient hydrochloric acid to make the entire solution 3 per 
cent. This is followed by absolute alcohol alone. Nicolle recom- 
mends carbol-water gentian- violet, made with 1 per cent, carbol- 
water and iodid solution as follows: One part of the iodid, 2 parts of 
potassium iodid, plus 200 parts of water. For decolorizing, he em- 
ploys an alcoholic solution of acetone. 

AATien decolorizing, after using Gram's stain special care must be 
taken, for if left in alcohol too long, even the Gram-positive micrococci 
will be decolorized, whereas if the preparation be left in loo short a 
time, Gram's negative bacteria will retain some of the stain. For this 
reason, when possible, it is advisable to place on one corner of the holding the material about to be examined a small quantity 
of a culture from some known Gram-positive organism, and on an- 
other corner a few anthrax or other Gram-negative micrococci. In 
this way control strains may be easily and certainly obtained. It is 
also an excellent plan to have at hand some gonococci of undoubted 
authenticity, to compare with doubtful specimens. These slides 
should be stained in the same manner as the slides containing the 
material for diagnosis. Weinrich' rejects practically all modifica- 
tions of Gram's stain, and warns especially against the use of acetone- 
alcohol (Nicolle's method), and still more against the use of acid alco- 
hol for decolorizing gonococci, these methods having a tendency to 
decolorize (iram-positive diplococci. Van Derbergh- and Pultrock' 
recommend absolute alcohol for decolf)rizing, but apply it for not more 
than thirty seconds, and never "until no more violet comes off." 

Koyes' stains the films for three minutes in a solution consisting of 
aniiiii oil, ,'5 parts; absolute alcohol. 7 parts: distilled water, 90 parts; 
these arc shaken well together and filtered through moist lilter-i)aper 

' Wciiiricli, M.iCf-nt. f. Hakt., etc., Aht., Joim, 1H98, vol. xxiv, |>i). 2.>S-26.">; also Ann. 
d. nial. <1. orj;. gcnito-uriii., Paris, 189S, vol. xvi, p. 504. 
'Van DiTborgh: Cr-nl. f. Bakt., vol. xx. 
' Paltrock: Der Cionokokkus N('i.s,scii, Doi-|iat, 1SI07, p. OS. 
' Kpycs, E. L.: of the Genito-urinary Organs, Hill, pp. 98-100. 


until the filtrate is clear; it is then stored for twenty-four hours and 
the supernatant fluid is pipeted off as required. After staining a 
number of slides in this solution one is washed off in water and exam- 
ined. If organisms morphologically similar to the gonococcus are 
discovered, other sUdes that have not been in water are placed in Lugol's 
solution (iodin, 1 part; potassium iodid, 2 parts; distilled water, 300 
parts) for two minutes. They are then transferred to absolute alcohol 
for exactly thirty seconds, and are afterward counter-stained with a 
solution of Bismarck brown, 98 parts, and phenol, 2 parts. 

According to Neisser,' the period required for decolorization by 
Gram's stain is dependent upon the medium in which the gonococcus is 
found. Thus it is said that gonococci in pure culture will decolorize 
in from fifteen to twenty seconds, in about twenty to thirty seconds 
when in pus, and in one minute when in mucus. The thickness of the 
film is also an important factor. Occasionally artificially grown gono- 
cocci retain the stain for a long time. In selecting material from cul- 
tures for staining purposes preference should be given to young colonies. 

Demonstration of Gonococcus in Dried Secretion. — The identifica- 
tion of the gonococcus in dried secretion, either on linen or on clothing, 
is under certain conditions possible even after prolonged periods. 
This point is sometimes of medicolegal importance. The author 
agrees with Ledermann,- who states that although it is possible to 
show gonococci from the clothing even after months or years, such 
demonstration, for forensic purposes, should be received with extreme 
caution. The presence' of gonococci is proved only when the bacteria 
are found in characteristic grouping, in leukocytes, when there is a 
chance for counterstaining with Gram's method, and when the organ- 
isms under suspicion correspond morphologically to the gonococcus. 
When in dried secretion, culture methods fail almost regularly, as the 
gonococcus is killed by prolonged drying. The difficulty of positively 
identifying the gonococcus in dried pus can be readily understood. 
Wachholz and Nowak' found micrococci in a spot of dried secretion on 
the skirt of a girl who had been repeatedly ravished. Their sup- 
position that the pus was from a gonorrhea was contradicted by the 
fact that neither the girl nor the malefactor had gonorrhea. Leder- 
mann,^ however, beUeves that these authors go too far when they state 
that cultures are the only certain method by which gonococci can be 
positively identified. At the Second International Medical Congress 

' Neisser, A.: In Kolle u. Wassermann, Handbuch f. Bakt., 1903, vol. iii. 
' Ledermann, R. : Amer. Jour. Dermat., November, 1910, vol. xiv. No. 11, p. 51. 
'Wachholz and Nowak: Vicrteljahressch. f. ger. Med., 1S95, No. 9; also Schmidt- 
mann's Handbuch f. gerichtliche Medizin. 
' Ledermann: Loc. cit. 



in Berlin, in 1S90, Kratter reported having demonstrated gonococci 
in dried secretion by the following method: The dried secretion was 
scraped from the linen and soaked for a short time in water, or the 
threads with the adherent remnants of the discharge were macerated 
and squeezed out. The gonococci were then stained by the usual 
method. Haberda^ experimented with this method. 'When he al- 
lowed a very thin layer of pus containing gonococci to dry on clothing, 
he could show the microorganism only after a few weeks. In thick 
layers, of which minute particles could be gained, gonococci were in 
evidence after eight months. But the characteristic marks had dis- 
appeared, and the differential diagnosis from other diplococci could 
not be made with certainty. Even worse were his results when he 
investigated material from chronic gonorrheas or when tUrty linen was 

Heger-Gilbert- employed the following method with better success: 
A small linen pad or piece of blotting-paper moistened with isotonic 
salt solution (0.9 sodium hydroxid in 100 parts of water) and rendered 
alkaline by the addition of sodium bicarbonate is placed in a watch- 
glass. The suspected piece of linen is cut out and laid on the pad and 
covered. After from one to five hours, according to the age, thickness, 
and dryness of the specimen, the droplets that collect underneath are 
obtained with a suction pipet and placed upon a slide, dried, and 
stained. By this method Heger-Gilbert was able to demonstrate 
gonococci in secretion that had been dried for two j^ears. 

Examination of the Urine for Gonococci. — In dealing with hyper- 
sensitive women, or for other reasons, it may be necessary to attempt 
to demonstrate gonococci in the urine. If this is the case, a morning 
specimen of urine .should be obtained, the patient having been in- 
structed to milk out the urethra with the finger while urinating. The 
urine shf)ul(l be allowed to stand for a short time in a conic urine glass. 
The sediment should then be centrifugalizcd at a high rate of speed 
(1200 involutions a minute) for three minutes, and large films of the 
pus and epithelial debris thus collected may be stained in the manner 
previously described. If a large amount of material is obtained at 
the first centrifugation, this may be mixed with normal salt solution 
and again ccnti-ifugated, under which circumstances the demonstration 
of the organism is somewhat facilitated. "Clap shreds" should also 
be examined. Some pathologists object to the use of the centrifuge 
because the molecular agitation tends to break up and destroy the 
leukocytes and epithelial cells, and thus make the intracellular demon- 

' Haberda: Quoted by I-cdcrmann: Loc. cit. 

'ircucr-dillicil: Soc. Hov. dcs .Sciences M(;il. ct Natuiellcs ilc Htiixelles, .luiic 1, IHOS. 


stration of the gonococcus more difficult. Such authorities recom- 
mend collecting the sediment in a conic urine glass after the specimen 
has stood for a few hours. The objection to the use of the centrifuge 
is more theoretic than practical. Fresh urine should be employed 
for cultures. Urine that has been passed for some hours is useless. 
It must be borne in mind that gonococci degenerate quickly in urine, 
and for this reason atypical forms may be present unless the urine is 

Attempts to demonstrate gonococci in the urine of women are 
usually unsatisfactory, and can be viewed only as makeshifts until a 
more thorough examination can be perfornied. Little or no reliance 
can be placed on negative findings. 

Although, as has been stated elsewhere, the staining character- 
istics previously described are not absolutely diagnostic of the gonococ- 
cus, they are, if properly carried out and if viewed in conjunction with 
the chnical symptoms, sufficiently exact for all practicable purposes. 
The decolorization by Gram's method is certainly the most character- 
istic staining properly possessed by the gonococcus, and is a test that 
should never be omitted in differentiating this microorganism from 
others morphologically similar. In examining secretion from the 
female genital tract gonococci may be so few in number and other 
microorganisms so numerous that the diagnosis is extremely difficult. 
If this is the case, a large number of films should be prepared and 

The following microorganisms are Gram positive : The streptococ- 
cus, the staphylococcus, and the pyogenic cocci in general, yeasts, 
molds, the pneumococcus of Frankel, the Micrococcus tetragenus, 
anthrax, tetanus, and tubercle bacilli, the bacteria of leprosy, diph- 
theria, swine erysipelas, and mouse septicemia, the potato bacillus, 
and some others. 

The following are Gram negative: The gonococcus, the Micrococ- 
cus melitensis, the Micrococcus catarrhalis (Pfeiffer), the typhoid 
bacillus, the Bacillus coli and similar bacteria, cholera and similar 
vibrios, the bacillus of fowl cholera, rabbit septicemia and malignant 
edema (the last is said occasionally to remain Gram positive), Fried- 
lander's plague bacillus, the glanders bacillus, the bacillus of influenza, 
the spirillum of relapsing fever, and the meningococcus. 

All the bacteria in the first list may be excluded by the proper 
application of the Gram stain. Of the second Ust, the Micrococcus 
meningitidis and the Micrococcus catarrhaUs are morphologically very 
similar to the gonococcus, and as they are both decolorized by Gram's 
stain, they cannot be excluded by this method. The Micrococcus 


catarrhalis is slightly larger than the gonococcus, but, owing to the 
variability in size of the latter, little significance can be attached to 
this feature. 

The Micrococcus citreus conglomerata (Bumm^j, the Diplococcus 
albicans amplus (Bumm'), the Diplococcus albicans tardissimus 
(Bumm'), and the Micrococcus subflavus (Bunim'), are all morpho- 
logicallj' somewhat similar to the gonococcus, but can be excluded by 
Gram's method. Another group of bacteria usually found in the 
sputum and nasopharyrrx, and which are saprophytic, catarrhal-like 
organisms, sometimes cause confusion. These have been described 
by Elser and Huntoon, who term them the chromogenic Gram-nega- 
tive cocci. Lingelsheim has studied these organisms carefully and 
gives the following list : 

Micrococcus pharyngeus sicca (Lingelsheim) , Micrococcus pharyn- 
geus cinereus (Lingelsheim), Diplococcus pharyngeus flavus I (Lin- 
gelsheim), Diplococcus pharyngeus flavus II (Lingelsheim), and the 
Diplococcus pharyngeus flavus III (Lingelsheim), are micrococci that 
diff'er from the Micrococcus catarrhalis only in the amount of j'ellow 
pigment they contain. 

Fortunateh', none of the organisms making up this rather formid- 
able list of Ciram-ncgative bacteria is often found in the genital tract, 
and this is especially the case in the male. Nevertheless, when a 
positive diagno.sis is required, either for sociologic or for medicolegal 
purposes, other means than staining have to be resorted to. For these 
cases cultures ofTer a method of absolute certainty in diagnosis. 

To Bumm's' indefatigable labors during the period of the early 
history of the gonococcus are we indebted for much of our knowledge 
regarding the growth of this microorganism on artificial media. It 
may be stated, at the outset, that the cultivation of the gonococcus 
in the laboratory is a somewhat difficult procedure, and should not 
be attempted without special technical bacteriologic training. The 
attempted diagnosis of gonorrhea by culture methods, unless per- 
formed by a skilled bacteriologist, is useless. 

Biology. The gonococcus grows best at Ijlood temperature, the 
extreme limits being 25° to 40° C. The optimum temperature is 
35° to 37° f ". Unfortunately, when within the human system gono- 
cocci are more resistant to variations in temperature. Attempts to 
cure anterior urethritis of gonorrheal origin by means of dry heat or 
the application of cold have not met with much success, although cold 
is undoubtedly a valuable adjunct to the treatment of specific ophthal- 

' Umniii, E. ; iJcr .Miknj-oi^aiii.simis nuiiDiTluii.sclicii Sclilciiiiliaut-Kikrankuiigi-n, Wics- 
biuli'n, 188.1. 


mia, but probably in this location acts as much by relieving congestion 
as by actually inhibiting the growth or attenuating the microorganism. 
The atmosphere should be somewhat moist. The organism is aerobic, 
and possibly slightly facultative anaerobic, but it does not grow along 
the hne of puncture when stick cultures are made in blood-serum. 
It does not produce spores, and is strictly parasitic, its habitation 
being the human body. The gonococcus is often associated with other 

Resistance. — When left at room temperature, cultures die in two 
or three days. When placed in the ice-box, they may live for several 
weeks, but usually perish moderately quickly. Gonococci are, how- 
ever, markedly more resistant to cold than are cultures of the meningo- 
coccus, which are always killed by temperatures approximating 0° C. 
Gonococci have but little resistance against outside influences, and 
are easily destroyed by weak antiseptic solutions, especially those that 
contain silver salts, as shown by the work of Schaeffer and Steinschnei- 
der.^ Gonococci in pus, when smeared on linen in thick layers, has 
been known to live for forty-nine days and twentj'-nine days when dried 
on a cover-glass. Complete desiccation, however, kills in a short time. 
According to Heiman,- incompletely dried and protected from the 
light, as in the case of pus, the gonococci may live in sheets or clothing 
for a considerable period of time. It is killed in six hours by a tem- 
perature of 45° C, and in thirty minutes by a temperature of 60° C. 
At the latter temperature its virulence is destroyed in ten minutes. 
Individual strains of gonococci exhibit marked variations in respect to 
their resistant properties. 

Culture-media. — The gonococcus grows sparingly on artificial 
media, and requires for its best development the addition, to nutrient 
agar, of a small amount of blood-serum or its equivalent, human serum 
being somewhat better than that obtained from the lower animals. 
After having been subcultured a few times, the amount of serum may 
be reduced, and, indeed, with some strains may occasionally eventually 
be almost entirely eliminated. The native protein is essential for the 
developmeiit of the gonococcus. The soil should be feebly alkaline or 
acid. For successful growth cultures require to be frequently trans- 
planted. This is especially important at first. After living in sub- 
cultures for a few months the periods of subculturing may be gradually 
lengthened. Some strains under such circumstances survive for 
periods of three or even six weeks, provided the proper moisture and 
temperature are maintained. 

' Schaeffer and Steinschneider : Kong. Deut. Dcrmat. Gesell., Breslau, 1894. 

2 Heiman: Studies from Path. Lab., College of Phys. and Surg., New York, 1895, p. 3. 


The great number of culture-media recommended by various au- 
thorities shows the lack of an ideal medium. Thalmann obtained 
primary cultures (subcultures failed) on his agar. Wildbolz^ suc- 
ceeded in maintaining a growth on agar after several subcultures on 
serum-agar. Vannon- and later Martin^ isolated and maintained a 
number of strains of gonococci on plain agar. WTien gonococci are 
successfully cultivated in serum-free media, the success has probably 
been due to material carried o\-er when making the culture. Subcultures 
usually fail. For successful cultivation of the gonococcus the con- 
sensus of opinion is that a preparation of uncoagulated albumin, de- 
rived from either man or animals, is an essential constituent of the 
medium. Neither hemoglobin nor urine is of especial service. Mar- 
tin'' has pointed out that a medium most rich in albumin is not neces- 
sarily the best, whereas small amounts of human serum markedly 
accelerate growth; large proportions have a decided bactericidal ac- 
tion on gonococci. When making cultures, surface inoculations are 
usually the most successful, as gonococci grow best in the presence of 
free oxygen. The culture material must be moderately moist, and 
for this reason manj^ authorities recommend capping the tubes or 
Petri dishes with rubber sheeting during incubation. Below follow 
the details of the method of preparation of a few media that have given 
good results: 

Bumrns Solidified Human Blood-serum (Abel''). — During the 
course of a normal delivery, when the cord has been ligated as usual 
with two ligatures and severed between these, the placental end is 
disinfected and cut through above the proximal ligature. The blood 
that exudes is collected in a sterile flask. This vessel is allowed to 
stand for twenty-four hours in a cool place. With a sterile pipet the 
separated, clear or slightly blood-stained serum is then removed and 
filtered into sterile test-tubes. The separation of the serum can be 
facilitated by loosening the blood-clot from the sides of the vessel with 
a sterile glass rod a few hours after the blood has been collected. The 
scrum may be converted into a transparent solid medium by heating 
for a variable time at about 70° ('., the test-tubes being slanted in the 
special apparatus tlesigned for this j)urpose. Although every effort 
may have been made, this serum is frecjuently not sterile. For this 

' Wildbolz, I[.: Ari-li. f. Dcmmt. u. .Sypli , \i(iui:i and I.i ip/JK, IDOli, vol. Ixiv, pp. 

^Viitinon: Cont. f. Hakl. u. I'aiasitciik., vol. .\1. p. HY>; ibid., 1907, AM. 1, orig. vol. 
xliv, p. 10. 

' .Martin, \\. W.: .Jour. PaUi. and \',iu:\., July, I'JIO, p. 70. 
' Martin, W. H.: ]jOc. cit. 

' .\l)i'l, R.: Laboratory Handbook of Bacteriology, tran.slatcd from the tenth edition by 
M. II. (lordon, London, r<)07. 


reason it should be sterilized by the fractional method and then, to 
make sure, the tubes should be placed in the incubator for twenty-four 
hours and those eliminated in which growth takes place. 

Another method is to pour the serum into medicine bottles. To 
these add plenty of chloroform. Park recommends using 5 per cent.; 
chloroform, being volatile, tends to disappear at ordinary tempera- 
tures, but is quickly and surely driven off at the temperatures used in 
sterihzing. Close the bottles with rubber stoppers. Store for several 
months, at the expiration of which time the serum is positively germ 
free. The chief disadvantage of this method is the time required. 
Sterilization by filtration is a tedious and unsatisfactory method. For 
most purposes the transparency of the serum may be sacrificed, for 
this is, as a rule, of no great value. Sterilize after solidification in 
slanting tubes by heating to 95° or 98° C, for one-half hour for three 
successive days, or the material may be heated to 100° C. at once. 
If the latter is done, the surface of the medium often becomes uneven, 
from the formation of bubbles. In whatever way prepared, the media 
should be tested in the incubator at 37° C. for twenty-four hours, and 
all test-tubes that show contamination eliminated. If it is desired, 
the medium may be allowed to solidify in Petri dishes and sterilized as 
just described. This has the disadvantage that the surface of the 
media dries quickly and extraneous organisms tend to find access to 
it. Ascitic or hydrocele fluid, obtained by aseptic puncture, can be 
used in place of the serum. The reaction is, however, sometimes very 
alkaline and should be tested. Should the placenta have been ex- 
pelled, it may be subjected to manual pressure and the blood obtained 
in this way. On this media, when solidified, cultures are made. The 
growth is not luxuriant. 

Wertheim Hwman Blood-serum and Agar Mixture {Ahel^). — Each 
of three sterile test-tubes receives 1 c.c. of fluid serum (obtained 
as just described), and all are then warmed to 40° C. The first tube 
is inoculated with gonococci; from it, the second; and from that, the 
third. Two c.c. of melted agar at a temperature of about 40° C. are 
then passed into each tube, and the mixture poured out at once into 
Petri dishes and allowed to solidify. Additional suspected material 
should be smeared over the surface of the solidified plates. It is then 
incubated. The colonies are larger than on the preceding medium. 
This is one of the best media. Some authorities believe that Wert- 
heim's- medium is improved by the addition of 6 per cent, glycerin or 
1 per cent, glucose. 

' Abel: Loc. cil. 

- Wertheim: Arch. f. Derniat. u. Syph., 1S99, voL xh, No. 1. 


Keifers Ascitic Agar (Abel^). — Neutral meat-extract agar, con- 
taining 3.5 per cent, agar, 5 per cent, peptone, 2 per cent, glycerin, 
and 0.5 per cent, sodium chlorid, is melted, and when it has cooled to 
50° C, is mixed with an equal quantity of ascitic fluid (obtained under 
aseptic conditions), and allowed to sohdify either in Petri dishes or 
in slanted tubes. The same precautions regarding sterility as are rec- 
ommended for Bumm's- medium should be carried out. Surface 
cultures are made on this medium. If the ascitic fluid is strongly al- 
kaline, it should be mixed with unneutralized or strongly acidified agar 
solution, so that the mixture will be rendered slightly alkaline. Aleyer^ 
employed this medium in 90 cases, and was able to cultivate the gono- 
cocci in 87 cases ; in onlj' 58 of these cases was it possible to demonstrate 
the microorganism in the secretion by means of the microscope. 

Abel's* Blood-smeared Agar. — The finger or some other por- 
tion of the skin is disinfected and then washed in sterile water to rid 
it of the antiseptics. A puncture is then made, and the blood thus 
obtained is smeared on the surface of nutrient agar. The test-tubes 
should be stoppered with sterile cotton. Surface cultures are made by 
taking a small quantity of the suspected secretion on the end of a 
sterile camel's-hair brush and rubbing this up with a drop of sterile 
blood. The mixture on the brush is then smeared over the surface of 
the medium after having first made sure of the sterility of the latter. 
This medium is reconmiended for subcultures chiefly because it is easy 
to prepare. The first generation does not always grow upon it. Cole 
and Meakins have had excellent results with this medium. 

Wright's Modification of Steinschneider' s Method.'-' — The details of 
the method as given by Wright are as follows: "A liter of nutrient 
agar is prepared in the usual manner, and after filtration it is evapo- 
rated to about 000 c.c. This concentration is desirable, so that after 
dilution with the urine and serum the medium may be sufficiently firm. 
This concentrated agar is then run into test-tubes, and the whole 
sterilized by steam on three successive days. The quantity of agar 
placed in each tube is smaller than is usual; this is in order to allow for 
the subscfiuent addition of the urine and serum. 

"The i)lood-serum, which need not be free from corjjuscles, is first 
passed through white sand, which is supported in a funnel by filler- 
paper, in order to remove, as far as possil^le, anj' particles in suspen- 
sion, and is then mixed with half its volume of fresh urine. The mix- 

'Abcl: Loc. cit. 

'Buram, E.: Dcr Mikro-DiKuiiisiiiusuDiiorrhoisi'licriSi-lili'imluiul-lMkniiikuMKi'M, Wics- 
badon, 188.5. 

'Meyor: Deutseli. nicd. Woch., l(tf«, vol. xxix, \o. :!('.. * Al)cl: Loc. cil. 

''Wripht:(2iiol("ill>yA.C'..Vl)l)olt;I'riMcii)l(>sof liiicterioIoKy.riKhtlMilitioii.lOO!), t).2!)0. 


ture of urine and blood-serum is next filtered by suction through an 
unglazed porcelain cylinder into a receiving-flask, such as chennsts 
use for sinnlar purposes, by means of a water-vacuum pump, ihis 
frees the mixture from bacteria. 

"The usual precautions are, of course, taken to prevent the con- 
tamination of the filtrate, such as the previous sterilization by steam 
of the cylinder and receiving-flask, besides others wliich will occur to 

any bacteriologist. , , . . . 

"To the agar in each test-tube, which is flmd and of a temperature 
of about 40° C , there is added about one-third to one-half its volume 
of the filtered mixture of urine and blood-serum. This is conveniently 
accomplished by pouring the mixture from the receiving-flask through 
the lateral tube, inserted near its neck dhectly into the tubes, ihe 
prehminarv melting of the agar is best effected in the steam sterilizer, 
in order that any organisms which have found lodgment in the cotton 
plugs of the tubes may be destroyed, men the agar is melted it is 
cooled and kept fluid by placing the tubes in a water-bath at 40 L. 
Each tube, after the addition of the urine and serum to the fluid agar, 
is quickly shaken to insure a uniform mixture, and is then placed in an 
inclined position to allow the agar to solidify with a slanting surface. 
When the medium in the tubes has sohdified, the tubes are placed in 
the incubator for about twenty-four hours to test for contaminations, 
after which they are ready for use." 

Naka-Abc Serum Mediu^n. -Tins serum is made by macerating 500 
grams of beef with 1 liter of water for twenty-four hours ^ the ice- 
chest This is then filtered through a Chamberland filter. The fluid 
is flasked and kept for four weeks, during which time its bactericidal 
portions are destroyed. It is then added to plain agar, in the propor- 
tion of 1 to 2 The originator claims excellent results for tlus medium, 
and asserts that the growth is always visible in eighteen hours. _ ^ 
Wassermann's' Nutrose Medium.— Mix in a flask lo c.c. of swine s 
blood 30 to 40 c.c. of water, 2 to 3 c.c. of glycerin, 0.8 gram of nutrose, 
and while constantly shaking the mixture, boil for fifteen minutes. 
Repeat boiling and shaking on following day. This fluid may now be 
stored. Before using, heat to 50° to 60° C, and mix with an equal 
quantity of sterile 2 per cent, peptone-agar. This medmm is excel- 
lent for surface subcultures. , ^ . 
Thalmann's Meat-extract Agar (A 6eJ=) .-Prepare meat extract 
follows- Take 500 grams of finely chopped beef, as free from 1 at aj 
possible, warm in a pot with one liter of water to 50° C, at which ter- 

■ 1 Wassermann: Zeit. f. Hygiene, 1S97, vol. xxvii; also Berlin, klin. Woch., 1897, No. 32. 
= Abel: Loc. cil. 


perature it should be kept for thirty minutes. Then boil for from one- 
half to three-fourths of an hour. Strain off the fluid from the meat. 
Add enough water to make one hter and then run into a flask, the 
mouth of which should then be stoppered with cotton. If this is to be 
preserved, it should now be sterilized by the fractional method, or by 
exposing it in an autoclave to a temperature of 100° C. for fifteen min- 
utes. To this solution add 1.5 to 2 per cent, of finely chopped agar. 
Two hours later, when the agar has become softened, add 0.5 to 5 per 
cent, of common salt. Heat gently in a steamer until agar is dissolved. 
Nearly neutralize with phenolphthalein. The acidity of the mixture 
must usually be reduced about two-thirds to three-fourths by the 
addition of caustic soda. The method of neutraUzation with phenol- 
phthalein is as follows: Place 5 c.c. of the medium in a flask, dilute 
with 45 c.c. of freshly prepared distilled water, and boil for three min- 
utes over a flame. Now add 1 c.c. of phenolphthalein (0.5 gram phenol- 
phthalein in 100 c.c. of 50 per cent, alcohol) and titrate with hj^dro- 
chloric acid until the fluid develops a red color. Add to the remainder 
of the medium, according to the result of this titration, experimental 
normal sodium hydroxid or normal hydrochloric acid until the reaction 
is neutral. Then titrate again a sample of the medium (5 c.c.) as 
directed above, and correct the reaction of the remainder, if necessarj'. 
Heat to boiling and test again. If the medium is now neutral or shghtly 
alkaline to phenolphthalein, it is strongly alkaline to litmus, since 
the peptone or diphosphate present in the medium is neutral or al- 
kaline to htmus, but acid or neutral to phenolphthalein. As media 
are more suitable for bacterial growth when neutral or slightly alkaline 
to litmus, media neutral to phenolphthalein must receive an addition 
of acid. Thus from 1.5 to 2.5 per cent, of hydrochloric acid (note how 
much) is added, and the mixture boiled, filtered, and steriUzed. For 
subcultures Thalmann reconnnends broth of similar reaction, or a 
serum may be made by mixing such broth with sterile scrum in equal 
parts and allowing it to solidify. 

Lipschiilz's^ Eg(j-nlhuimn Agar Culture-medium. — To 3 parts 
ordinary peptone agar or broth add one part alkaline 2 per cent, egg- 
alhunien solution. Merck's finely powdered egg-albumen is recom- 
mended by Lipschiitz. This is readily soluble in water. The albu- 
min solution may be filtered and sterilized before adding the agar to it. 
This medium is easily made, and the albumin can be obtained without 
difficulty. The originator of the method states that he has grown 
gonococci in this medium to the thirty-fifth generation. 

' Lipschiitz: Cent. f. Bakteriologie, 1904, vol. xxxvi. 


Baer's^ Medvum.-Baev recommends the following medium. Hy- 
drofdeplem-itic, or ascitic fluid is collected under aseptic condi ions 
in sterie flasks. This is placed in test-tubes and tested f or stenhty m 
the t ubator for twenty-four hours at 37° C. All tubes that exhibit 
Irowth are discarded. The sterile transudate is then mixed with 
Sai" agar that has been previously condensed to two-thirds of its 
ulk in tiie proportion of one part of transudate to two parts of agar. 
The t Ludatel added to the agar in test-tubes, the agar having b^en 
melted and cooled to 45° C. The tubes thus prepared are capped with 
Irle rubber and allowed to solidify in a slantmg position. The 

?Ws medium is used for surface cultures. The condensed water m 
le tXs assists in spreading the suspected secretion over the surface^ 
BowhilVs"' MediuM.-^A good liquid medmm, recommended by 
Bowhill may be prepared by mixing 1 part of human blood-serum with . 
9 par sofpeptone bouillon. In this medium the gonococci form a 
membrane on the surface, whereas the medium itself remains almost 
Sely clear. In preparing this medium animal blood-serum may 
bf Substituted for human serum, although the toiler is the better. . 
Nevertheless, gonococci grow quite well on swine 

Heiman^ Chest Semm.-Pleuritic or hydrothorax A^^^/^ f «™- 
To this is added 2 per cent, agar broth, 1 pex cent, peptone, wi h o 
without 5 per cent. salt. Heiman beheves that the excellence of this 
ni^dium for'the cultivation of gonococci is due to the large amount o 
a bui^n which it contains. Other fluids that may be substituted for 
th c'e ttid are peritoneal fluid, chronic synovitis effusion, hydrocele 
tld pericardial fluid, the fluid contents of ovarian cysts, and hydro- 
salpinx fluid. Heiman, however, prefers the chest serum^ 

Martin's^ Medium.-Beef-extract is prepared in t^e usual manner 

To it are added 0.5 per cent, of disodium f^'^'^'Flt^Tt)^- 
cent of Witte's peptone, and 2 per cent, of powdered agar The nnx 
ture is pLed in a Koch steriUzer, and after the agar has been melted 
and wtS^e still hot, the medium is titrated. For this purpose 5 c.c. o 
the sample medium is taken, to which are added two drops of 0.5 
per ceTtBolution of phenolphthalein ; normal sodium hydroxid solu- 
tion is added from a buret until a faint but perman^n pink color 
Xch c^stinctly deepens on cooling, appears. This is taken as th 
Ind point, and if the medium is of the correct degree of acidity (0.6 

1 Baer: Jour. Infec. Diseases, 1904, vol iv, PP- 313-326. 

2 Bowhill: Manual of Bact. Tech. and Special Bact., N. Y., 190-, p. -4. 

3 Heiman, H.: Med. Record, N. Y., vol. In., p 80^ 

4 Martin, W. B.: Jour. Path, and Bact., July, 1910, p. 76. 



per cent, to phenolphthalein or + 6 on Eyre's scale), 0.6 c.c. of soda 
solution will have been used (in the proportion noted). In practice, 
however, more alkali is at first required. For example, if 2 c.c. were 
used, then the medium is 1.4 per cent, to acid. This is corrected by 
adding to the medium, in bulk, normal sodium hydroxid solution in the 
proportion of 1.4 c.c. to each 100 c.c. of medium (usually somewhat 
more than the calculated figure is actualh' requisite). The reaction 
having been adjusted, the medium is filtered, tubed, and sterilized as 
usual. Care should be taken to avoid prolonged cooking, as this 
causes a darkening of the medium, and increases the difficulty of 
titration. If white-of-egg has been used for clearing purposes, allow- 
ance must be made for the fact that it is usually more acid than the 
medium. TMien properly prepared, the medium is nearly colorless 
and should possess only a moderate amount of water condensation. 
For use: On the surface of each slanted test-tube three or four drops 
of sterile (exposed to 57° C. for one and one-half hours) human blood- 
serum, obtained under aseptic conditions, are placed. The tubes are 
then tested overnight in the incubator, to make certain that they are 
still sterile. In case of plates, the serum is added to the agar after it 
has been melted and cooled to 45° C, in the proportion of 0.2 c.c. of 
serum to 5 c.c. of medium. To avoid drying, the test-tubes should be 
capped with sterile rubber. As gonococci are sensitive to room- 
temperature, it is best to make inoculations direct from subject to 
medium in the incubator when possible. After isolation it is advisable 
to make frequent subcultures to maintain recent strains. ^Martin 
prefers to isolate by means of stroke cultures rather than by shake 
plates, although in articular effusions the latter method is better, the 
centrifugatod fiuid being used. This medium has the advantages of 
transparency, economy of scrum, and is suitable for cither plates or 
slanted tubes. 

Duval's Method of PreimriiKj Blood Agar. \ base of 2 per cent. 
agar is prepared; ])(>ptone, 1 per cent, and sodium chlorid, 0.5 per cent., 
are added to beef infusion. This is corrected to 0.6 per cent, acid to 
phenolphthalein (hot titration) before sterilizing in the autoclave. 
To the tubed sterile agar, melted and cooled to a temperature of 52° 
C, is added a small quantity of sterile defibrinated human blood. 
From 4 to 7 drops of blood are added to each 6 to 10 c.c. of agar. The 
tubes are then shaken and slanted, or the contents poured into Petri 
dishes. By this means a beautiful, bright crimson, almost trans- 
parent, inodium is oljtaiiied, possessing a moderate aniovmt of water of 
condeiisatidii. If llic agar is hotter tluui 60° ('., when the blood is 
added, the liciiiiigl(il)in is dcst foycd and a (hrty bi-owii mixluic is tiii- 


result. If the agar is too cool, there will be no water condensation. 
This medium is improved by keeping it for one to two weeks before 
using. The tubes may be stoppered with rubber or, better, with 
paraffined corks. This medium is recommended by Gurd.^ 

Thalhimer^ recommends the following for a simple laboratory 
method: Freshly drawn beef blood, obtained from an abattoir, is col- 
lected in a wide-mouthed jar and defibrinated by shaking with a num- 
ber of medium-sized marbles. This is laked by adding an equal part 
of distilled water and rendered free from bacteria by means of a Reichel 
filter. The filtrate should be a clear red fluid. From 20 to 30 c.c. of 
this are added to 1 liter of sterile melted agar at 45° C, and the result- 
ing mixture is then poured into sterile tubes. The medium that results 
is perfectly clear, bright red, and of the same shade as ordinary blood- 
agar. On this medium organisms that were unsuccessfully tested on 
hemoglobin agar were successfully passed through a number of gen- 
erations. Gonococci grew luxuriantly. This method is a modifica- 
tion of former methods, notably that of Pfeiffer, and is believed to be 
the simplest yet devised for preparing blood-agar. It is evident that 
the hemolytic quaUties of an organism cannot be tested with this 

Youncfs^ Media.— Sterile hydrocele or ascitic fluid obtamed by 
modern surgical methods is mixed with nutrient agar. A number of 
common agar slants are put in the autoclave for five minutes. This 
liquefies the agar and sterilizes the tubes and cotton stoppers. The 
slants are then put in a water-bath at 55° C. The stopper having 
been taken from a small flask of hydrocele fluid, the top of the flask is 
flamed and the fluid then poured on an agar tube, the top of which has 
been flamed, in proportions a httle more than one to two. The agar 
tube is then stoppered and slanted. When plate cultures are to be 
used, sterile tubes containing about 7 c.c. of hydrocele fluid are em- 
ployed. These are inoculated and mixed with melted agar slants at a 
temperature of 40° C., the two being poured separately into a Petri 
dish. Young prefers the slant method, and has kept gonococci alive 
on these for three months. The hydrocele or ascitic fluid, if uncon- 
taminated, may be kept for several months before use. 

According to some writers, human urine, steriUzed by filtration 
through porcelain and added to a mixture of blood-serum and agar, 
facihtates the growth of th*e gonococcus. Cultures have also been 
grown on acid gelatin, gelatin containing acid urine, in acid urine itself, 

1 Gurd: Jour. Med. Research, 1910, vol. xxiii; n. s., vol. xviii, p. 154. ■ 

= Thalhimer, W.: Bull. Johns Hopkins Hospital, August, 1911, p. 293. 

■■> Young, H. H.: Contributions to the Science of Medicine, Baltimore, 1900, p. 677. 



and in albuminous urine with agar. These media are, however, un- 
certain and of doubtful value. 

Reaction of Culture-media. — This detail is of the greatest impor- 
tance, and inattention to it, or different testing methods employed, 
doubtless accounts for the many varjdng results obtained by cUfferent 
investigators in the cultivation of the gonococcus. Finger, Ghon,' and 
Schlagenhaufer (1894) postulated a reaction frankly acid to litmus 
as essential. Thalmann" (1900) laid the optimum reaction between 
neutrality to litmus and neutrahty to phenolphthalein. Vannon^ 
prepared a medium faintly alkahne to litmus, and finally Gurd^ pro- 
posed a medium of the reaction of 0.6 per cent, acid phenolphthalein, 
whereas Pollock and Harrison^ recommend a reaction of -t- 6 Eyre's 
scale. Until comparatively recently litmus was the most generally 
u.sed indicator for neutralizing media, adding normal sodium hydroxid 
solution until red litmus turned slightly blue or blue Utmus a shade less 
blue. Phenolphthalein is a much more accurate and sharper indicator 
than litmus, and has the advantage of being colorless in acid solution 
and pink in alkahne. It should be remembered that different indica- 
tors varj' not only in delicacy, but react differently to various sub- 
stances. A medium that is alkaline to litmus may be acid to phenol- 
phthalein, showing that there is present in such mixtures an acidity 
that litmus does not detect. These substances are organic compounds 
or acids, theoretically amphoteric, but in which the acid character 
predominates. Thus a hter of bouillon becomes, on the addition of 1 
per cent, peptone, more alkaline to litmus, but decidedly more acid to 
phenolphthalein. In cultivating the gonococcus the reaction of the 
medium is of the greatest importance, and for this reason tests by 
phenolphthalein should always be resorted to. In using phenolphthal- 
ein care must be taken to eliminate the effects of carbon dioxid, which 
is acid to phenolphthalein. For convenience sake titrations of media 
should be made as nearly 100 c.c. as possible. All media should in- 
variably be tested for twenty-four hours in an incubator at 37° (\, 
iinincdiatcly prior to its use, to ascertain its sterility. 

Appearance of Colonies. — Colonies of gonococci can usually Ik' de- 
tected macroscopically at the end of twenty-four hovu's; however, 
gonococci vary somewhat in the speed with which they develop col- 
onies, and for this reason it is advisable to incubate suspected cultures 
for at least three days unless a growth is obtained prior to this time. 

' Ohon, PfcifTer, ami Sederl : Zeit. f . klin. Med., 1902, vol. xl. ' Tluvliiiaiin : Loc. cit. 

• Vnnnon: Cent. f. »;ikt. ii. Piini.sitonk., vol. xl, p. 102; ibid., 1907, 1. Aljt., orig. vol. 
xliv, p. 10. 

' (liinl: Lnc. ril. 

' Pollock, C. K., :iiiil lliirrison, L. W.: (loiiocorcal Iiifcrlions, London, 1912. 


As a general rule, it may be stated that gonococci grow slowly on arti- 
ficial media, and that a delicate growth is characteristic. Colonies 
are usually small. Their appearance varies somewhat with the me- 
dium on which they are cultivated. In color, the colonies are grayish- 
white, opalescent, with often a tinge of yellow, especially toward the 
center. At the end of twenty-four hours they usually appear as small, 
isolated, circular, raised, translucent, finely granular colonies, the edges 
of which are scalloped or crinkled. The margins appear to fade grad- 
ually into the surrounding culture-medium. The granular appearance 
is particularly noticeable toward the periphery. In the center, small 
grayish or yellowish punctate spots of high refraction are often seen. 
Surface streak cultures usually appear as translucent, granular, gray- 
ish-white growths with rather well-defined thick edges. At the end 
of three days colonies frequently measure only 1 or 2 mm. in diameter. 
Under careful cultivation on suitable medium, colonies may, however, 
attain a diameter of 1 or 2 cm. Cultures grown on the Wertheim^ me- 
dium, at the end of twenty-four hours appear as previously described. 
The superficial colonies exhibit a dark spot in the center, from which 
a delicate, finely granular coating extends arovuid the colony. The 
deeper colonies are grayish-white and present an uneven appearance. 
At the end of two or three days they acquire somewhat the shape of a 
blackberry, whereas on the surface there is a moist, yellowish growth, 
from the border of which, under the low power, small processes may be 
seen extending. At this stage such cultures must be transplanted or 
the colonies are likely to perish. In reinoculating from the colonies 
they are found to consist of shining, tenacious, compact masses. 
Stroke cultures on oblique, solidified blood-serum-agar (Wertheim-) 
produce moderately luxuriant growths. At first these appear as 
isolated, grayish colonies, which later become moist, slimy, and tena- 
cious, and from the margins of which a film-like coating extends. 
Gonococci do not hquefy blood-serum. Growth on Martin's' medium 
appears in from eighteen to twenty-four hours. The colonies are 
minute, semitransparent, slightly elevated discs, presenting to the 
naked eye a moist, glistening surface. By low power, with transmitted 
fight, they appear almost transparent, and are a light grayish yellow. 
They are homogeneous, the ground-substance being finely granular. 
They have definite uniform margins, which, with the high power, are 
seen to be slightly toothed. As the colonies enlarge they tend to re- 
main discrete; the center thickens and becomes more opaque, owing 
to the development of numerous ovoid, coarse granules. At the end of j 

' Wertheim: Arch. f. Derm. u. Syph., 1S99, vol. xli, No. 1. ■ Wertheim: Lnc. cil. 

» Martin. W. B.: .lour. Path, and Bact., July, 1910. p. 76. 


from fortj'-eight to seventy-two hours the margins are scalloped. 
Thus radial striations develop, and concentric rings, due to different 
zones of opacitj', also appear. Finally, when about a week old, coarser 
granules become visible. These are often so white and opaque in 
contrast to the remainder of the colony as to suggest contaminations. 
The growths may readily be removed on a platinum loop, and are dis- 
tinctly viscous in consistence, although neither slimy nor tenacious. 
On Duval's medium colonies can be macroscopically distinguished in 
from eighteen to twenty-four hours, occasionally being delayed for 
forty-eight hours, ^^^len the colonies are fully developed they appear 
as watery-looking, bluish gray or almost colorless, semitransparent, 
small, round excrescences having a fairly well-developed outline. 
At the end of seventy-two hours colonies show a tendency to spread 
from the periphery in a somewhat irregular manner. 

In old cultures the appearance of the colones varies widely. At 
times they may be found to be simply a mass of more or less Gram- 
negative material. Heiman^ has maintained a culture for three 
months, but this is an exceptionallj' long period for a culture to exist 
without transplanting. As a rule, they die in a much shorter period. 
The morphology of the individuals of very old colonies often in no 
way resembles ordinary gonococci. Nevertheless, such material re- 
inoculated on suitable culture-medium may produce gonococci that 
are typical in mode of growth, staining reaction, morphology, and in 
pathogenic character. A successful inoculation from a culture of the 
twelfth generation was performed by Aufuso. A similar result was 
obtained by Buniin from the twentieth generation. 

Method of Testing Colonies. — (1) Films may be prepared and 
stained with the ordinary stains and by Gram's method. Few cocci 
other than the gonococci are Gram-negative. (2) Subcultures should 
be made on ordinary agar. If the organism is the gonococcus, there 
is no growth. (This applies only to freshly isolated cultures. Oc- 
casionally certain strains of gonococci will be encountered, which, 
after having Vjeen grown on artificial media for a number of gen- 
erations, seem to adapt themselves to their surroundings and will 
thus grow on ordinary laboratory media.) There is no growth on 

Animal Experimentation. — The gonococcus is strictly parasitic 
'Hutrnii ), and seems to attack man exchisivel}', for gonorrhea cannot 
be |)ri((luc('<i ill the iowci- aniinMJs. Kxcii tlie aiithi'dpoid apes ai'i' 

' Ilcirnaii: Studies from ilii' l':illi. Lai)., C'olloKC I'liysician.s and Siiincons, Niw York, 
189.5, p. :i. 

' Hiiiniii: Wit's Handliiiili dcr ( lynakolo(tip, vol. ii. 


immune to this disease (Wildbolz^). Neisser inoculated dogs, with 
negative results. Loffler and Leistikow^ inoculated the abraded con- 
junctiva and urethra of rabbits and guinea-pigs without result. 
Krouse' attempted to infect rabbits, cats, pigeons, and mice. Wert- 
heim^ claims to have produced a mild peritonitis in mice, rabbits, and 
rats by inoculation of gonococci. Finger also has reported having 
produced an inflammation of the knee-joint of a dog from a pure cul- 
ture of gonococcus grown on serum-agar. These results were probably 
produced by toxins which are present in both the living and the dead 
gonococci. Indeed, it is to these substances that the discharge of 
gonorrhea is attributed. 

Toxins. — The gonococcus develops a gonotoxin. This is present in 
the cells after heating and contact with alcohol. The production of a 
toxin has been demonstrated by Wassermann,^ de Christmas,^ and 
others. There is still some doubt as to the exact nature of the toxin, 
some believing that it is set free only by the disintegration of the gono- 
cocci, — in other words, an endotoxin, — whereas other authorities con- 
sider it a product of bacterial metabolism. 

Rogers and Torrey^ state that the repeated injection of free gono- 
toxin in culture-media had a disastrous effect on rabbits that were 
used in the production of antigonococcic serum. Although the ani- 
mals suffered Uttle from the first 5 or 6 inoculations, they soon after 
reached a condition of hypersensitiveness to the toxin and finally 
succumbed to a dose that would never have proved fatal to a normal 
animal. This seems to indicate, as Wassermann^ and others have 
pointed out, that the toxin in culture-media is not produced in diffus- 
ible form by the living gonococcus cells, but is an endotoxin derived 
from the dead and disintegrated gonococci. 

Injections of small quantities of gonotoxin in rabbits or mice pro- 
duce no results. In large quantities fever, infiltration, and sometimes 
necrosis are produced. If the injections are persisted in or the doses 
are very large, loss of weight and, finally, death occur. Inoculated 
into the urethra of man, a transient urethritis is produced. The toxin 
injected into the cellular tissue of man produces a painful celluhtis 

' Wildbolz, H.: Zent. f. Bakteriologie, vol. xxxi, Xo. 4. 
^ LofflcT and Leistikow: Charite-Annalen, 7. Jahrg. 
' lu-ouse: Cent. f. AugenJieilk., 1882, p. 134. 
* Werlheim: Arch. f. Dermat. u. Sj-ph., 1899, vol. xli, No. 1. 

^Wassermann: Zeit. f. Hyg. u. Infektions-foankh., vol. xxvii, Xo. 2: also Berlin, 
klin. W och., 1897, No. 32. 

« de Christmas: Ann. Institut Pasteur, 1897; also ibid., 1900, vol. xlv, p. 331. 
■ Rogers, J., and Torrey, J. C: Jour. Amer. Med. Assoc, September 14, 1907. 
» Wa-sscnnami : Quoted by Rogers and Torrey: Loc. cii. 


which lasts several da3's. Repeated injections probably give no im- 

The filtrate prepared from recent cultures of gonococci contains 
little or no toxin. 

The exact part which the toxin plays in the production of infection 
is still undetermined. It is not known if the poison is capable alone 
of producing metastases, or if any parts of the body are especially 
susceptible to it, if it can diffuse itself throughout the body, or if its 
action is purelj' local and intimately associated with the presence of 
the gonococcus itself. 

Nikolaysen^ claims to have isolated the toxin by means of distilled 
water or sodium hydroxid from the bacterial bodies. This toxin is 
found to remain active after complete drying or after exposure to 120° 
C. of heat. Nikolaysen found the toxin quite as poisonous to animals 
as was a pure culture of living gonococci, 0.01 gram killing a white 
mouse. Specific injury to the nervous system by the injection of a 
gonococcal toxin has been described by Moltschanoff.- 

Immunity. — If man possesses any immunity at all, it is extremely 
transient — so short lived, in fact, as. to be of no practical value. On 
account of the chronicitj' and frequent latency of gonorrhea, this point 
is difficult to determine positively. Animals may be jiartially im- 
munized to the toxin, in which case their blood is said to possess slight 
antitoxic and bactericidal properties. Torrej'^ has produced immunity 
in guinea-pigs. 

Agglutination. — This test is of no great practical diagnostic value. 
The gonococci, Uke certain other pathogenic cocci, possess many 
strains that differ markedly in their specific character and have but 
few common agglutinins. 

Bacteriologic Properties of Micrococci Likely to be Confused with 
the Gonococcus. -Under this heading may he placed a gi'ouj) of micro- 
organisms known as tlie pscudogonococci. This name has been ap- 
plied to them In' ]Mannaberg, Lustgarten, andBunnn.'' These organ- 
isms are morphologically very similar to the gonococcus, but may be 
distinguished from the latter by their method of growth and staining 
properties. The identity of this group of microorganisms as special 
germs has been established. They are usually regarded as varieties 
of skin or air cocci that have accidentally obtained access to the genital 

Micrococcus Cilreus Conglomerala (Bumm*). — This microorganism 
' Nikolaysen: Cent. f. Biikt., l.S'J7; also Fort. ti. Med., 1S'.)7, vol. xxi. 
2 iMoltschanolT: Munch, nicd. Woch., 1899. 
' Toiri-y, J. C: Med. Kasearch, 1908, p. ;J47. 
* Huintn: Vfit's Handb. der Gyn., vol. ii. 


is morphologically similar to the gonococcus. It is Gram-positive, 
easily cultivated, and forms colonies that grow on and dissolve gela- 
tin. On the surface of the latter the micrococcus grows rapidly and 
forms a moist, shining, unwrinkled growth. The organism is not 
pathogenic. It is found in the air and in gonorrheal pus. 

Diplococcus Albicans A^yiplus (Bwnm'^). — This diplococcus is found 
in the normal lochia, and is considerably larger than the gonococcus. 
It Uquefies gelatin, and on this medium produces a grayish-white 
colony. Its growth is moderately rapid. In staining reaction the 
organism is Gram-positive. 

Diplococcus Albicans Tardissimus (Bumni). — This micrococcus is 
Gram-positive, and has been found in urethral pus. On the usual 
culture-media it grows slowly at ordinary temperatures, but more 
rapidly at 37° C. It does not hquefy gelatin. Colonies appear as 
small white excrescences that, under the low power, are opaque, semi- 
translucent, and brown. Agar stroke cultures present a grayish-white 
growth. In old colonies the surface is wrinkled. 

Micrococcus Subflavus (Bumm). — Is Gram-positive and has been 
found in the lochia and urethra of healthy women. This micrococcus 
grows slowly on all media. On gelatin it produces a moist, yellowish- 
brown colony that liquefies the medium slowly. On potatoes the 
Micrococcus subflavus produces, at the end of two or three weeks, 
crescent-shaped colonies that have a wrinkled-skin-like surface and are 
light brown in color. Pathogenesis: Has no action on mucous mem- 
branes, but wheh injected into cellular tissue produces an abscess in 
the pus of which large numbers of diplococci may be found. Wormser- 
states that the Micrococcus fallax may be mistaken for the gonococcus, 
but may be distinguished from the latter by culture methods. This 
author states that the Micrococcus fallax does not react regularly 
with Gram's stain, but is usually negative. The coccus is easily de- 
stroyed by weak alkaline solutions, but is extremely resistant to 
solutions of potassium permanganate. The gonococci may be dis- 
tinguished from the pseudogonococci by the fact that — (a) The former 
can usually be found intracellularly. (b) They are Gram-negative, 
(c) They do not grow on gelatin (at least in the first generation, and 
only very exceptionally at any time), (c) The micrococci just men- 
tioned are all easily cultivated, whereas the gonococci grow only spar- 
ingly and with difficulty, and only upon special media. The fermenta- 
tion test is here of value. This depends upon the acid reaction, which 
is produced by the growth of the organism with various sugars. The 

' Bumm, E. : Der Mikro-organismus gonorrlioisfheii Schleimhaut-ErkMnkungen, Wies- 
badon, 1SS5. 

- WormscT, L.: Annal. dcs Maladies Gen.-rrin., Mart-h 20, UllO. 



organism is grown in litmus broth and ascitic fluid containing glucose, 
galactose, maltose, or saccharose. According to Mayou,^ the follow- 
ing reaction is obtained: The gonococcus gives an acid reaction with 
glucose and galactose. Meningococcus gives an acid reaction with 
glucose, but not with galactose. ]M. catarrhalis gives no reaction 
with either. 

Elser and Huntoon- present the following table, showing the value of 
sugar fermentation in the identification of the aforementioned bacteria : 

Strains Tested 





Micrococcus catarrhalis 

Micrococcus pharyngeus siccus 2 

Chromogenic Group I 28 

Chromogenic Group II 11 

Chromogenic Group III I 9 

.laeger moningococcus ( Krai) 1 

Diplococcus cra-ssus (.Krai) 1 




















Meningococcus or Diplococcus Intracellular is Meningilidis. — This 
micrococcus is Gram-negative. ' It gives luxuriant and rapid growth 
on a wide variety of media. In serum bouillon it produces a turbidity 
that is later deposited at the bottom of the test-tube. The young 
colonies have delicate, almost invisible margins, the centers of which 
later become grayish-white. The meningococcus is occasionally 
present in the female genital tract. It may produce oi)hthalmia, and 
has been found in the blood and spinal fluid. The enzymotic proper- 
ties are irregular and similar to those of the gonococcus. Both or- 
ganisms act in much the same manner when kept in the same media and 
environment, but the meningococcus is the stronger grower (Flexner'). 
This is especially so of cultures two or more days old. The meningo- 
coccus is frequently found in or on the cells. 

Pollock and Harri.son'' sum up the differences between the gonococ- 
cus and the meningococcus when grown on artificial media by stating 
that, in general, the meningococcus is less sensitive to changes in tem- 
perature and reaction of the medium, grows more rapidly on scrum 
agar, and its colonies are more opaque than those of the gonococcus, 
and that it can generally be cultivated on plain nutrient agar. The 

' Mayou: The Practitioner, London, 1908, pp. 125, 200, and 3.54. 
' Elscr and Huntoon: Quoted by P. H. Hiss and H. Zins.ser; A Text-book of Bac- 
teriology, 1910, p. 387. 

' Flexncr, S. ; .lour. Expcr. Med., March, 1907. 

' Pollock, C. E., and Harrison, L. W.: Gonococcal Infections, London, 1912, p. 20. 


meningococcus degenerates even more rapidly than the gonococcus. 
The meningococcus forms acid with maltose and dextrose, while the 
gonococcus ferments dextrose only. Martin^ states that on his 
medium the edges of the colonies of the meningococcus are more trans- 
parent than are the colonies of the gonococcus. 

Micrococcus Catarrhalis. — This organism was first described by 
R. Pfeiffer- in 1896, and in the same year is referred to by Frosch and 
Kolle. Later Ghon, H. Pfeiffer, and SederP and von Lingelsheim^ 
carefully studied this microorganism. 

Its habitat is the respiratory tract, especially the nose, mouth, and 
throat. It has also been found in the eyes. Gurd^ and others have 
found this micrococcus present in the inflamed genital tract of men and 
women. According to Gurd, the micrococci described by von Lingels- 
heim,^ and called by him Micrococcus pharyngeus sicca, M. pharyngeus 
cinereus, Diplococcus pharyngeus flavus I, D. pharyngeus flavus 
II, and D. pharyngeus flavus III, differ from the Micrococcus catarrh- 
aUs and one another only in the amount of pigment that they develop, 
and which gives them their yellow color. In cUfferentiating these 
micrococci from the gonococci Gurd lays especial stress on the fact 
that the latter produce a dehcate growth, which is comparatively 
restricted to serum media of a particular reaction. This microorgan- 
ism is Gram-negative, and grows readily on gelatin at room tempera- 
ture. It is an active grower on most media. In serum bouillon it 
forms a scum, and later deposits, but does not produce turbidity. 
The colonies have an opaque, white, shining appearance. Park and 
Williams^ state that the Micrococcus catarrhaUs does not liquefy 
gelatin, and that on bouillon it produces a cloudy growth, with, often, 
the development of a pedicle. Milk is not coagulated by this micro- 
organism, but dextrose serum may be. As the colonies develop the 
centers become elevated and the edges crenated. The surface 
colonies of gonococci are grayish, bluish, or whitish, and are radially 
plicated, concentrically striated, have granular centers, scalloped mar- 
gins, and present a poor growth (sUght granular deposits) in serum 

Libman and Cellei-^ found that the Micrococcus catarrhalis was 

' Martin, W. B.: Jour. Path, and Bact., July, 1910. 

= Pfeiffer, R.: Die Mikroorg., tiiird edition, 1896. 

» Ghon, Pfeiffer, and Sederl: Zeit. f. klin. Med., 1902, vol. xl. 

* von Lingebheim : Klin. Jahrbuch, 1906, vol. xv, 2. 

' Gurd: Jour. Med. Research, 1910, vol. xxiii; n. s., vol. xviii, p. 154. 

' von Lingelsheim: Loc. cit. 

' Park and Williams: Pathogenic Bacteria and Protozoa, New York, 1908. 

« Libman and Celler: Reports of Mt. Sinai Hospital, 1903. 


more nearly oval in form than the gonococcus, and slightly larger. 
Aj'res^ believes that this organism is responsible for a definite propor- 
tion of cases of urethritis; that these infections are characterized 
clinically by the mildness of their onset, and are often mistaken for 
gonorrhea. According to Ayres,- such cases should not be treated 
locally, as they get well without treatment, whereas the apphcation of 
silver preparations may cause them to continue indefinitely. The same 
writer reports cases of pelvic inflammatory diseases due to the Micro- 
coccus catarrhahs, one being a mixed infection with the staphylococcus, 
and the other being due probably to the Micrococcus catarrhahs alone. 
Hiss and Zinsser^ and Libman and Celler^ state that the Micrococcus 
catarrhalis is of slight pathogenicity. 

In 1906 von Lingelsheim^ described the Diplococcus mucosa. The 
colony formation is similar to the meningococcus, but is somewhat 
more mucoid in character. This microorganism can easily be distin- 
guished from the former and from the gonococcus by capsular stains, 
as by them it will be found to possess a cUstinct capsule. 

Bacteriologic Diagnosis of Gonorrhea. — In the great majority of 
acute cases gonorrhea may, to all intents and purposes, be diagnosed 
positiveh' by the morphology and staining reaction of the gonococcus 
found in film preparations, and this is especially true in the male. No 
other micrococcus possessing the same appearance and staining prop- 
erties, and capable of producing the clinical symptoms of an acute 
severe urethritis, has ever been demonstrated in cultures from this 
region. In chronic cases staining methods offer a less certain means of 
diagnosis, not only because the gonococci are present in reduced num- 
bers, but particularly on account of the fact that in these cases the 
specific micrococcus is often atypical in size, shape, and staining re- 
action. Finger, Schaeffer and Steinschneider,^ and Galewski found 
that a Gram-negative diplococcus which was not the gonococcus oc- 
curred in only from 4.(j per cent, to 4.8 per cent, of cases in a large series. 
This shows that over 95 per cent, of cases can be correctly diagnosed 
by the Gram method of staining. In all cases of doubt — and this 
refers particularly to old chronic or latent cases, where the patients 
desire to marry, and in everj^ case in which the medicolegal aspect is 
likely to be involved, or where an absolute diagnosis is desired, as in the 
case of rare lesions — cultures should be made. Because of the difficulty 

' Ayres, W. : Amer. Jour. Surg., New York, March, 1912, p. 101. 

'Ayres: Loc. cU. 

' Hiss, P. H., and Ziasscr, H.: A Text-book of Bacteriology, 1910. 

* Libman and Celler: Loc. cil. 

' von Lingelslu^im: Klin. Jahrb., 190C, vol. xv. 

' ■Selincffcr and Stoin.sehneider: Kong. Dcut. Derniat. Cicseil., Breslau, 1894. 


in cultivating the gonococcus on artificial soil the cultures should be 
undertaken only by an experienced bacteriologist. If negative re- 
sults are obtained, either by the staining or by the culture method, 
repeated examination should be made under the most favorable cir- 

IMcFarland^ summarizes the characteristics of the gonococcus 
as follows: Non-sporogenous, non-liquefying, non-chromogenic, non- 
flagellate, aerobic, strictly parasitic, not stained by Gram's method, 
requiring special culture-media, and pathogenic only to man. In- 
deed, Wertheim- and Schanz^ state that negative culture tests must be 
always viewed with suspicion on account of the capriciousness with 
which many stains of gonococci grow even upon the most favorable 
artificial media. Of late years, however, the routine cultivation of the 
gonococcus on artificial media has been carried out with marked suc- 
cess. Thus Butler and Long'' state that they experienced no cUfnculty 
in cultivating this organism from a large series of cases, and while it 
is undoubtedly true that the gonococcus requires a special medium for 
its development and care must be exercised regarding the temperature 
at which it is incubated, it seems probable that in the past the dif- 
ficulty in cultivating the organism has been somewhat overestimated. 
A point of the utmost importance in securing material for cultures is 
that, when possible, the material be obtained by curetage of the dis- 
eased area. Thus in arthritis the joint fluid, be it serum or pus, will 
be negative in a much larger proportion of cases than will be particles 
of the granulation tissue that can be secured by scraping the cavity. 
Gurd^ has emphasized this point regarding cultures from pus- tubes, 
and states that the negative results often obtained are due to this fact. 
It is well known that prolonged encapsulation tends to destroy the 
vitality of the gonococcus, which will often be dead or of greatly les- 
sened virulence in pus, while active organisms may be found in the 
walls of the abscess. 

Diagnosis op Gonorrhea by the Complement-fixation Test 
In 1906 Miiller and Oppenheimer"^ suggested applying the comple- 
ment-fixation test as a means of diagnosis in cases of gonorrhea, and 

' McFarland, J.: A Text-book upon Tathogenic Bacteria and Protozoa, Philadelphia 
and London, 1912. 

' Wertheim: Arch. f. Dermat. u. Syph., 1899, vol. xli, No. 1. 

^ Schanz: Deut. med. Wochonschr., Leipzig and Beriin, 1004, vol. xxx, p. 350. 

' Butler, W. J., and Long, J. P. : 111. Med. Jour., 1908, vol. xiii, p. 538. 

' Gurd: Jour. Med. Research, 1910, vol. xxiii; new series, vol. xviii, p. 15-4. 

" Miiller and Oppcnhoimer: Wien. klin. Woch., 1906, No. 19, p. 894. 



reported one case in \\-hich the method had been successful. Further 
investigations on this subject have been published by Bruck,i Meak- 
insr Vanned,' Wollstein/ Torrey/ Watabiki/ Kohler/ 'Eising,^ 
Gradwohl,^ and Schwartz and McNeil.i" The last-mentioned investi- 
gators have applied the complement-fixation test to a series of 324 
human sera. These sera were taken from persons of both sexes 
having acute or chronic gonorrheal infection; from others having no 
history of chnical manifestations of gonorrhea, and from patients 
suffering from various diseases other than gonorrhea. Schwartz and 
McXeil used many different strains of gonococci in the preparation 
of the antigen; in other words, a polyvalent antigen. In the great 
majority of the cases tested, clinically 12 strains of gonococci were 
used m the preparation of the antigen. This antigen seemed to give 
more uniformly accurate results than some prepared from only 6 
strains. In their work they used both antisheep and antihuman 
hemolytic sera and followed the technic laid down in the well- 
known Wa.ssermann test for .syphihs, and in Noguchi's modification 
of the Wassermann test. Among 29 women in whom gonorrhea was 
defimtely present or suspected, 23 were positive and 6 were negative. 
Among a miscellaneous series of 20 cases, in none of which a history or 
phyi^ical signs of gonorrhea were 'present, 10 were positive and 30 
negative. In a series of pregnant women the following results were 
obtained : 35 cases showed no .'^igns of gonorrhea ; 14 were positive and 
21 negative. One pregnant goiiorrheic was positive and one pregnant 
patient with a marked antepartum discharge in which no gonococci 
were found was negative. The table on p. 82 is a summary of the 
results obtained by Schwartz and McNeil. 

In a later communication Schwartz and McNeil" confirm their 
previous conclusions. They state that a positive reaction can rarely 
be obtained before the fourth week of the disease, and that the reaction 

' Bruck, C: D.-uis.-l.c „i(d. Woch.. l<)(Hi, xxxii. p. VMiS. 
'Mciikins: .Inhn.s Hopkins Ho.-ip. Bull., 1007 \(, Is p >-,-, 

• Woll.stcin: Jour. Exper. Mod., 1!)07, No. 9, p. 588. 

' Torrcy, J. C: .Jour. Mod. Kosoarch, 1907, No. 17, p. 223. 

'Hutubiki, T.: Jour. Infoc. Di.s., lilio, \o. 7, p. 15<). 
FixJion Tos; l^;V,)\''''\'^li"v)^'™;''''''«']'-' •^''vw.'.l'.'r '•), 191 1 ; \aluo of Iho Con.plonunt- 
2^19 "nSS)' T 'V'i':''"'' ;""' '^'';'."'" •^"""■■^' •'"'"• A.nor.Mod. Asso,., 

Wi !{^nI:^';iHV p''l:S ^"■■"'''■■■"•■"-"'-'""" '<-'■'-■ Ai.s.raot and Disoussion 

" Kising, E. 11.: Mod. Kocord, .Juiio 1, 1012. 

^ (iradwohl, U. B. H.: Amcr. .Jour. Domiat., 1912, vol. xvi, No. 6, p 294 
p.69:j'!^'''"''"''''' "• ■'■' ""'' ^''■^'■"' '^•- '^""''- •'"""•• ^'<-''- ««'•- 101 1. new series, vol. oxli, 
'■ Sduvuru, H. .1., a,.d .\I,\,.il, A.: Anu-r. .lour. Mod. .Soi., I>oo>nl.or, 1012, p. S1.9. 



persists for seven or eight weeks after cure; that the reaction is often 
absent if only the anterior urethra is involved. 


Positive I 




Clinical Diagnosis 

OF Cases ; 


Per Cent. 


Per Cent. 

1. Acute gonorrheal urethritis: 

(o) Duration three days to three 






(bj Duration not stated 

2. Acute urethritis: 

Oonococcus not found 




3. Chronic uiethritis (gonorrheal;: 

(fi^ Gonococcus present 




fj^\ Oonococcus not founo 






(c) No examination made for gono- 

cocci, but serum taken from cases 

at stage when gonococci are usually 






4. Chronic urethritis: 

Gonorrhea doubtful 






5. Chronic prostatitis: 



(a.) Gonorrheal history 




(b) Gonorrheal history doubtful ... 


1 ■ 




6. SteriUty, gonorrheal history 






7. Epididymitis: 

(a) Gonorrheal history 






(b) Gonorrhea denied 






8. Verumontanum cases: 

(d) Gonorrheal history 






(b) Gonorrhea denied 






9. Miscellaneous cases with no sign or 

history of gonorrhea 




10. Gonorrhea in.male cUnieally cured . . . 






11. Cases treated with bacterins 




12. Joint affections: 

(a) Gonorrheal arthritis 




(b) Gonorrheal arthritis questionable 






(c) Other ioint affections 






13. Pregnancy cases taken from public 

maternity hospitals 






14. Gynecologic cases: 



(a) Gonorrhea definitely present or 







(6) Cases with no signs or history of 






1 66 


It would seem, from the foregoing, that the complement-fixatio 
test should be a decided adjunct in the field of cUnical pathology as 
an aid in the diagnosis of gonorrhea. Swinburne^ and Keyes^ re 
gard this test very highly. Schmidt^ presents the following results 
which he has obtained in 77 cases : 

1 Swinburne, G. K.: Trans. Amer. Urol. Assoc., 1912, vol. v, p. 21. 
^Keyes, Jr., E. L.: Trans. Amer. Urol. Assoc, 1912, vol. v, p. 40. 
'Schmidt, L. E.: Ibid., p. 30. 




Clinical Diaonosis 

Acute gonorrhea 14 

Chronic gonorrhea 32 

Epididymitis 11 

Artliritis : i 5 

Gonorrheal history of from one to ten years I 27 

Gonorrheal history negative i 11 

Number Per Cent. Number Per Cent. 


It seems to be of especial value in the diagnosis of joint condi- 
tions. Schmidt,' after having tested the complement-fixation test in 
103 cases, states that the results indicate that a negative test in 
a patient is good evidence that the disease is cured. Gardner and 
Clowes- report that in a series of 106 gonorrheal cases 23 showed a 
three-plus reaction, 15 a two-plus, 23 a one-plus, whereas 37 were 
negative. Of the 23 cases showing a three-plus reaction, 20 were 
examined, in 18 of which an intracellular diplococcus was found. Of 
the 15 cases giving a two-plus reaction, 13 were examined, in 9 of 
which an intracellular diplococcus was demonstrated. Of the 23 
cases showing a one-plus reaction, 17 were examined, and in 11 an 
intracellular diplococcus discovered. These authors believe that the 
three-plus and two-plus reactions are fairly diagnostic of the presence 
of gonorrhea, while a one-plus reaction, without being confirmed by 
clinical data, should not be regarded more seriously than should a one- 
plus Wassermann reaction. Gradwohl,^ after an experience with 50 
cases tested with the complement-fixation test, states that this test 
does not appear to have nearly so many hmitations as does the Was- 
sermann test for syphilis. It is a genuine antigen-antibodj^ test. 
A gonorrheal fixation test once positive and later negative is of great 
value in estimating a cure. In persons recently infected the test is 
apt to be negative. Schwartz* states that a positive reaction should 
not be expected earlier than about the beginning of the fourth week 
from the onset of the infection. Irons" states that occasionally in 
adults, and more frequently in children, a fairly positive reaction occurs 
in persons who have never had gonorrhea. It would seem that the 
test should be especially valuable in the case of women in whom, dur- 
ing the chronic stage, gonococci are very difficult to demonstrate. 

To l)e of any value whatever, the complement-fixation test must 
be carried out by a siiilled bacteriologist, and every technical pre- 

' Schmidt, L. E.: Jour. Amer. Med. Assoc. April 27, 1912, p. 1307. 

' Gardner and Clowes; Jour. .^mcr. Med. Assoc., April 27, 1912, p. 1307. 

• Gradwohl, U. B. H.: .\mcr. Jour. Denniit., June, 1912. 

* Schwartz, H. J.: Amer. Jour. Med. Sci., Septcmlier, 1912, vol. cxliv, No. 3. 
' Irons, E. E.: Jour. Infec., July, 1912, p. 77. 


caution observed. A positive reaction indicates a focus of gonorrhea 
in some part of the body, but a negative test does not necessarily 
exclude the disease. It is at once apparent that acute gonorrhea will 
not show a positive result until sufficient time has elapsed to pernut 
the absorption of enough toxin to cause a systemic response to in- 
vasion, as shown by the antibodies of various types in the serum. 
The test is usually negative until about the tWrd or fourth week. In 
subacute or chronic gonorrheas the chances of a positive result are greatly 
hicreased, the percentage of positive results being about as high as in 
similar tests for syphilis. In cases of gonorrhea that are supposedly 
cured, a positive reaction would indicate a focus of infection somewhere 
in the system of such virulence that transmission of the disease would 
be more than likely to follow, provided the focus was so situated that 
transmission was possible. But it must be remembered that gonor- 
rheal antibodies persist for some time after the disappearance or de- 
struction of the invading gonococci. 

A negative result cannot justify in any way the exclusion of gonor- 
rhea, as in not a few cases that have been bacteriologically proved to be 
gonorrhea a negative reaction was obtained. Gardner and Clowes^ state, 
however, that in the 185 tests made by them a positive reaction was never 
obtained in any but a gonorrhoic. Schwartz, = after reviewing addi- 
tional cases than those previously recorded, concluded that the test is 
of great practical value. O'Neil,' after a series of 256 tests, is of a 
similar opinion. 

More research will be required before the exact value and scope of 
the complement-fixation test can be definitely determined. 

Diagnostic Vaccination.— In 1908 Irons^ noted that subcutaneous in- 
oculation of dead gonococci in persons suffering from gonorrhea fre- 
quently was followed in from twelve to twenty-four hours by local and 
general reaction. This reaction consists of an area of redness, swelling, 
and tenderness at the site of the inoculation, often an increased pain and 
tenderness in affected joints and other localizations, together with symp- 
toms of malaise and sometimes increase in fever and leukocytosis. These 
phenomena resemble those seen in the tuberculin reaction, and are of 
value in the diagnosis of obscure cases in which gonococcal infection 
is suspected. This reaction has been noted by many investigators. 
Reiter^ observed the reaction in women suffering from pelvic inflam- 
matory diseases of gonococcal origin. Irons" states that in positive 

' Gardner, J. A., and Clowes, C. H. A.: New York Med. Jour., October, 1912, p. 734. 

2 Schwartz, H. J.: Amcr. Jour. Med. Sci., September, 1912, p. 369. 

' O'Neil, R. F.: Bo.ston Med. and Surg. Jour., October 3, 1912, p. 464. 

* Irons, E. E.: Jour. Infect. Dis., 1908, vol. v, p. 279. 

' Reiter: Zeitschr. f. Geburtsh. u. Kinderh., 1911, vol. Ixviii, p. 471. 

6 Irons, E. E.: Jour. Amer. Med. Assoc, March 30, 1912, p. 931. 


cases an area of hyperemia 5 to 10 mm. in diameter appears around 
the point of inoculation, and that not infrequently a definite papule 
develops. Sakaguchi' has arrived at similar conclusions. Sternberg- 
concludes, after an extensive study of this subject, that the diagnostic 
vaccination is of much practical aid in the diagnosis of gonorrhea. 
In normal persons used as a control either no reaction occurs, or at 
most a small area of redness, 2 to 3 mm. in diameter, develops. Eising^ 
recommends intradermal injections, and states that these are followed 
by a more pronounced reaction than either epidermal or subdermal. 
This author states that the papule measures from 3 to 5 mm., is slightly 
tender, and often surrounded by an areola 5 to 10 mm. in diameter. 
The papule appears in from twelve to twenty-four hours after inocu- 
lation, and persists for a varying period, but never longer than one 
week. Shngenberg,^ von de Velde,^ Recio,^ London,^ and others report 
favorably upon the diagnostic value of vaccine. Like other tests, this 
will, no doubt, be found to have its limitations, and further research is 
required before its value and scope can be definitely determined. 

Leukocytosis in Gonorrhea. — Wile* has studied the question of 
leukocytosis in cases of gonorrhea. Fifty cases were employed, includ- 
ing men, women, and children suffering from various lesions. Wile 
concludes that gonorrhea presents no typical blood-picture, but varies 
with the individual case, the stage of the disease, and the variety of 
the lesion. In his series there was a slight decrease in the polynuclear 
neutrophiles, while the mononuclear were slightly increased. 

The Gonococcus and Mixed Infection. — Finger, Zweifel, Kronig, 
and .Jadassohn'-' state that genital complications of gonorrhea are 
cau.sed by the gonococcus alone, but that metastatic complications, 
like glandular involvements, arthritis, cardiac lesions, and skin ab- 
scesses, are usually' caused by a mixed infection. Menge'" believes that 
mixed infections in the female play a very unimportant role, and that 
true mixed infections seldom occur. He further states that in gon- 
orrhea in the female complications by continuity and by metastasis 
are caused by the gonococcus of Neisser alone, but that other organ- 
isnis have often Ix'cn found, these being, however, due to secondary 

' SakiiKUclii, v.: iJciiiiut. W'ocliciisclir., T/oipziR .and llamliurn, 1912, vol. liv, p. 71!l. 

- StcrnborK, A. .J.: (iyn. HiindMcliau. 1!I12. 

' HisiiiR, E. H.: Mod. Koroni, .luiif 1, 191'J, p U)3S. 

' SiiriKcnberg, B.: Arch. f. Gyn., licrlin, 1912, vol. xcvi, No. 2. 

' von do Vc'Idc, T. H.: Monats. f. tioburt. u. Clyn., Berlin, April, 1912, vol. xxxv, No. 4. 

Krcio, A.: Hivi.sia di .Mcdicina y Cinirgia, Havana, .•\i)ril 2."), 1912. 

London, .J.: Anicr. .Med., April, 1912. 

\\ ilc, ,J. S.: .\mor. .lour. Med. Scl., new scries, HKMi, vol. cxxxi, p. 1().")2. 
' FiiiKcr, Zweifel, Kninin, .ladius.solin; Quoted hy K. Menne: Ilandhucli iler (ie- 
Rehleehlslcrankheiten, Vienna, 1910. 

\Unni-: llaiidl>iicli d. ( liwlileclil-^kranklieilcn, \icniia. 1910. 



infections — as, for instance, a pyosalpinx in which mixed infection 
with the Bacilhis coU commune, the latter organism having entered 
the tube secondarily from the intestinal tract. Certainly in acute cases 
pure cultures of gonococcus are much more likely to be obtained than in 
chronic cases. The locahty invaded is of importance in this connection, 
as obviously some structures are more prone to a secondary infection with 
another microorganism than are others. Thus in gonorrheal proctitis 
the infection is always a mixed one, and the same is probably true of 
the oral cavity. This question of mixed infection of the various organs 
will be dealt with more fully in subsequent chapters. It is sufficient to 
state here that, in the author's opinion, mixed or rather secondaiy in- 
fections are by no means infrequent, especially in chronic cases, and 
when employing vaccine therapy this fact must be borne in mind. 


Action on 


-l- = acid 

Oroanibm and 

Growth on Nu- 

Growth on 

=iio reaction 


TR08E Acetic Agar 
AT 37° C. 

Gelatin at 20° 










M. catarrhalis, 

Opaque ; granu- 

Positive. (Grows 

Mice and guinea- 

nasal and 


on ordinary 

pigs by intra- 

pharyngeal dis- 

agar at 37° C.) 

peritoneal in- 


oculations only. 



— — . 

M. intracellu- 

Clear; smooth. 


In some cases 

laris (menin- 

mice and 

gococcus), cere- 

guinea-pigs by 

brospinal men- 






+ — 

M. gonorrhoeae 

No growth unless 


In some cases 


blood added. 

mice and 

urethral dis- 

guinea-pigs by 






From nasal dis- 

Clear, smooth, 

Negative at first, 

Mice and guinea- 

charge from 

and becomes 

later posit 


pigs by intra- 

Hartford's case 


(Grows on 


peritoneal in- 

of influenza- 

dinary agar 



like epidemic. 

37° C.) 



From nasal dis- 

Opaque; gran- 


Mice and guinea- 

charge from 


pigs by intra- 

Hartford's case 

peritoneal in- 

of influenza- 


like epidemic. 





From urethra. 

Opaque; some- 
what granular; 
smooth edges. 


Mice and guinea- 
pigs by intra- 
peritoneal in- 






M. melitensis 

Creamy and 


Monkeys, also 

Malta fever. 

slightly yel- 

rabbits and 
guinea-pigs, by 


' From Dunn and Gordon, Brit. Med. Jour., 1905, vol. ii, p. 427. 



In no disease, perhaps, is a more thorough knowledge of path- 
ology necessary for an intelligent comprehension and studj* of the 
symptoms and treatment than in gonorrhea. It is the author's belief 
that the pathology, symptomatology, and treatment of any given dis- 
ease should be studied coincidentally, for only in this way can the three 
branches be satisfactorih^ understood. In order for the clinician and 
the pathologist to reap the greatest benefit from their labor, the lab- 
oratory and the cUnic should be closely associated. Given a thorough 
knowledge of the pathologj', the symptoms resulting from the patho- 
logic changes can be more or less closely worked out. For example, 
the symptoms and recurrent character of BarthoUn's abscess are en- 
tirely explained by a study of the histology and anatomy of the gland. 
The same may be said, in a somewhat broader sense, of those numerous 
and varied lesions generally classified under the heading of Pelvic 
Inflammatory Disease. The patulous tube, with its leakage of in- 
fected material, is productive of active pelvic peritonitis, with its ac- 
companj'ing symptoms; the closed tube, with its perhaps more mas- 
sive pathology, and its often less marked subjective symptomatology; 
the sterilitj' due to endometritis or the occlusion of the tube or 
interference with the maturation and rupture of the Graafian follicle; 
the adhesions to the bladder or rectum, with their accompanying dys- 
uria or rectal symptoms, are also thus explained. So almost the 
entire category of symptoms may be elucidated by a study of the 
pathology of the individual case. A correlation of the pathology and 
the symptomatology is, therefore, of the greatest advantage. In the 
same way a knowledge of the pathology is of great aid in selecting the 
best form of treatment. 

In previous pages an attempt has been made to depict the method 
of invasion of the gonococcus to the genital tract of the female and the 
type of lesions produced. The infection almost invariably begins as 
a surface inflammation, and spreads thence more or loss deeply into 
the underlying structures. The gonococcus may lie dormant, es- 
pecially in areas below the internal os, for a prolonged jieriod, but if 



the proper stimulus is applied, it is ready to spring into activity. On 
the other hand, protracted encapsulation, such as frecjuently occurs in 
the adnexa, tends to destroy the organism. In the latter location the 
prolongation of symptoms may be traced to three definite causes: 
reinfection, either autoinfection, from the cervix and endometrium, 
or from without, may occur; or secondary infection may result and the 
lesions be actively continued by organisms other than the gonococcus; 
and, lastly, the scar tissue or adhesions resulting from the active in- 
fection may persist and produce symptoms. 

Many more or less indirect results of gonorrhea also occur. Thus 
the gonococcus is believed to prepare the soil for subsequent infec- 
tions, such as tuberculosis, or for the pyogenic organism; tubal carci- 
noma seldom occurs in previously normal tubes, whereas the loss of 
cilia in the tubal epithelium and kinks of the tube resulting from ad- 
hesions are known to be strong predisposing factors of tubal pregnancy. 

In .localities invested by adult squamous epithelium, such as the 
vagina, the gonococcus rarely produces serious lesions, the inflammation 
being usually due to the irritating toxin-laden discharge constantly 
passing over the surface. It is true that gonococci may occasionally 
be fovmd in the depth of and among the cells of the squamous epi- 
thelium, but the organisms do not appear to thrive in these areas. 
On true mucosa, however, a different condition exists: the surface 
epithelium becomes swollen, and the cells become separated from one 
another by the inflammatory exudate. Many of the cells are desqua- 
mated, and are ultimately replaced by a modified epithelium — in 
some instances non-ciliated columnar, and in others even by squamous, 
epithelium; or cicatricial tissue may result. The gonococci quickly 
gain access to the glands, in which similar changes occur in the invest- 
ing cells. As a result, periglandular inflammation is usually a marked 
feature. In some instances the gland-openings become occluded and 
finally become filled with inflammatory exudate, resulting in the for- 
mation of the pseudo-abscesses of Jadassohn. As the process advances, 
the epithelium and its basement-membrane may be entirely destroyed, 
and a true abscess, surrounded by a pyogenic membrane, may occur. 
This condition is not infrequently seen on the vulvovaginal gland, or 
the deeper epitheUum of the gland may escape or be but temporarily 
involved, and, as a result, occlusion cysts are found. A similar pathol- 
ogy may occur in the cervix, and to a less marked extent in the cor- 
poreal endometrium or the mucosa of the tube. The gonococci in the 
glands may persist long after a surface cure has been obtained, or may 
from this location tend to aggravate the surface inflammation by re- 
infection. This tendency to glandular penetration possessed by the 


gonococcus is of importance in considering the treatment of the dis- 
ease, and, to a large extent, accounts for the resistance to gonococcids 
as ordinarily applied to the surface mucosa. 

From the surface and glands the gonococcus escapes to the stroma 
of the mucosa, and thence to the underlying muscular layer, or even, 
in severe cases, to the serosa or adjacent structures. As a result, the 
stroma of the mucosa and the underlying tissue become swollen and 
infiltrated with inflammatory products and the blood-vessels become 
congested. These changes vary with the stage, severity of the dis- 
ease, and the area attacked. As a result of desquamation of the sur- 
face epithelium or long-continued inflammation in the depths of the 
mucosa or underlying tissues, cicatrices maj' be formed, and by their 
contractile properties produce pathologic changes and a continuance 
of symptoms long after all signs of active inflammation have subsided. 
This fact is of especial importance when considering the symptomatol- 
ogj^ and treatment of intraperitoneal pelvic lesions. By this process 
an extensive pathology may be greatly curtailed, and result in "the 
derehcts of the gonococcal storm," as they have been aptly termed by 
Sanger. There is no doubt that but for this tendency toward the 
formation of scar tissue, the proportion of cases of pelvic inflammatory 
disease ultimately requiring operative intervention after properly carried 
out palliative treatment would be greatly reduced. In other words, 
many old, chronic cases suffer more markedly from adhesions and con- 
tractions than from the actual infection. This, of course, does not 
apply to those cases — and thoy are many — that exhibit more or less 
frequent or prolonged exacerbations. 

From the method of invasion, the most marked ])athologic change 
is usually found near the surface. The tissue in tliis locality seldom 
undergoes complete resolution, evidences of past disturbances nearly 
always remaining. The chief characteristic of gonococcal inflamma- 
tion is its chronicity. The much mooted question, as to whether or 
not the gonococcus produces lesions suflRciently characteristic to dif- 
ferentiate them from other forms of infection, without a study of the 
bacteriology of the individual case, will be more thoroughly discussed 
in subsecjuent pages. 

Vulvitis in the adult is a not infrequent accompaniment of gon- 
orrhea of the cervix or urethra. In infants and young children the 
infection usually spreads to the vagina, producing a vulvovaginitis. 
In the young, on account of the delicacy of the skin over the affected 
areas, the lesions are likely to be more i)r()n()unccd. (Sonorrhea may 


produce the most severe grade of vulvitis. During the acute stage the 
labia majora and minora, the clitoris, and the adjacent structures are 
reddened, swollen, and tender. The affected area is bathed in a more 
or less profuse purulent discharge, which contains numerous gonococci. 
The chronic vulvitis, which often continues after the acute process has 
subsided, is characterized by similar symptoms, all of which are, how- 
ever, less pronounced. Although some redness usually persists, the 
edema and swelling are, as a rule, less marked, and tenderness is either 
absent or greatly decreased. The discharge is yellowish or brownish 
in color, thick, but less profuse, and contains fewer gonococci than 
during the acute stage. In neglected or careless patients yellowish or 
brownish crusts may form, and in severe cases, when these are removed, 
bleeding ulcers may be found beneath. Evidences of Bartholinitis 
and of urethritis can generally be found. Condylomata are not in- 
frequent, especially in neglected cases or when pregnancy is present. 
Histology. — The histology resembles that of an ordinary dermati- 
tis, and varies in acuteness and extent of involvement according to the 
individual case and the stage of the infection. 

Bartholin's glands (named after Bartholinus,^ who described these 
structures in detail in the seventeenth century) are structures usually 
about 3 to 5 cm. in length, and having a diameter of 2 to 4 mm. The 
ducts vary somewhat in length, but average about 1.5 cm., and at the 
outlet have a diameter of about 0.5 mm., but widen as the gland is 
approached. In their widest portion they have a diameter of about 2 
or 2.5 mm. Before reaching the gland the duct divides into two or 
three trunks, which in turn subdivide so that finally each lobule of the 
gland is drained by a small duct. The gland and its ducts have 
been appropriately likened to a bunch of grapes somewhat more 
developed on one side than on the other, the duct representing the 
stem, and the lobules, the grapes. The outer part of the duct is lined 
by multiple layers of squamous epithelium. In the deeper portions 
transitional epithelium is present. The small ducts which finally enter 
the gland present a somewhat varying histologic picture: in some in- 
stances they are lined b}^ transitional epithelium; in others, by cylin- 
dric or cuboid cells. On cross-section the glands are found to be 
round or oval, and are invested by a single layer of high cylindric 
epithelium. These cells often contain large quantities of mucus, and 
under these conditions are of the goblet type, and are not dissimilar to 
the glandular elements of the cervix, except that the protoplasm does 
1 Huguier: Memoires de I'Academie de M(5decine, Paris, 1856, vol. xv, p. 531. 



not take the hematoxylin stain. The glands are tubular or racemose, 
and are contained in a thick framework of connective tissue and non- 
striped muscle. The glands and adjacent tissue are rich in blood- 

Bartholinitis may occur independently, or as an accompaniment 
of \ailvitis. Although theoretically cysts and other manifestations of 
barthohnitis maj' be the result of various forms of infection, if carefully 
studied, the great majority of cases can be traced to gonorrhea. Of 
14 specimens of cysts and 21 specimens of abscesses of this structure 
in the Gynecological Laboratory of the University of Pennsjdvania, 
all were clinically associated with gonorrhea. Veit^ beheves that 
barthohnitis is nearlj' always of gonorrheal origin. Suppurative proc- 
esses are, however, frequently due to mixed infection. As a result of 
gonorrheal infection of Bartholin's gland, various lesions may be pro- 
duced. More or less well-marked redness and swelling, often somewhat 
resembUng a mosquito-bite, — the so-called gonococcal maculfe of 
Sanger, — are present about the exit of the gland whenever the struc- 
ture becomes inflamed. The gonococcal maculse persist for prolonged 
periods, even after lengthy intervals of quiescence of the disease. 

Cyst. — In 1861 Breton- described cysts of Bartholin's gland, this 
being, perhaps, the earliest description of these lesions. If the in- 
flammation is limited to the duct of the gland, partial or entire occlu- 
sion of this structure may result, and be followed bj' the formation of a 
retention cyst. Cj^sts of Bartholin's gland may occur in the duct or 
in the gland, or both structures may be involved, depending upon the 
situation of the occlusion. The tumors may be unilateral or bilateral, 
the former being the more common. Cj'sts due to occlusion of the 
orifice of the duct are of the most frequent variety, and are always 
unilocular. These tumors are pyriform in shape, the large end being 
directed downward. \Miile iti situ, if the tumor is of moderate or 
large size, the vulvar cleft is distorted. These cysts are usually about 
the size of a pigeon's egg, and, as a rule, grow slowly, although rapid 
increase in size is sometimes noted. This may in some instances be 
due to hemorrhage occurring in the cavity of the cyst. When a cyst 
of the duct is present, the gland is pushed upward and outward. 
Cysts of the gland proper are, as a rule, more spheric, nioi-e deeply 
placed than cysts of the duct, and show a tendency to extend into the 
rectovaginal septum. Cj'sts that occur in the gland or in the depths of 
the duct where it has subdivided may be multii)le. Cullen'' reported 
a series of 17 cysts of Bartholin's gland. • The smallest of these was 

'Veil: Ilanrlbuch (ler Gyniikologie. 'Breton: Th6se de Stra.shourg, 1861. 

' Cullen, T. C: Jour. Amor. Med. As.soc., .lamiary 21, 1905, p. 204. 


5 mm. in diameter, and the largest, 4 cm. Kleinwaditer^ asserts that 
retention cysts of this locahty are rarely larger than a hen's egg. In 
the author's series of 14 cases, the largest was 8 cm. in diameter, and 
all were unilateral. Small cysts produce no subjective symptoms, 
and patients are frequently not aware of their presence. They are, 
however, not infrequently observed during the routine gynecologic 
examination, and are quite often discovered accidentally while per- 
forming plastic operations on the perineum. Wiener- has reported the 
history of an unusual case in which the cysts were bilateral and meas- 
ured respectively 11x8 and 12 x 5 cm. An unusually large specimen 
of this form of growth has recently been described by Dartigues.^ 
If removed without rupture or when examined in situ, the cysts are 
moderately tense and fluctuant. After removal the outer surface is 
roughened at the point where the tumors have been shelled out or 
dissected free from their bed of adhesions. On section, the walls are 
found to vary quite markedly in thickness in different specimens and 
in different parts of the same specimen. The walls are, as a rule, 
moderately dense. The lining is generally smooth, although some cir- 
cular or crescent-shaped openings are often present, indicating dilated 
gland openings. The cysts are usually unilocular, although occasion- 
ally two or more cavities are present, this point depending upon the 
location of the occlusion. The cyst contents generally consist of clear 
serous fluid, but they may be of a chocolate color, owing to the ad- 
mixture of blood. As a result of infection, the contents are sometimes 
turbid or purulent. 

Histology. — The microscopic picture varies ciuite widely in different 
specimens. As a rule, areas of comparatively normal gland are pres- 
ent. The cyst lining differs according to the point of origin of the 
cyst. If the cyst is due to the occlusion of the main duct near the 
outlet, the investing epithelium will naturally be largely squamous in 
type, whereas if the occlusion has been in one of the secondary ducts, 
the lining epithelium may be transitional or cyUndric. Not in- 
frequently all varieties of cells are present in different portions of the 
cyst. In large cysts, in those of long standing, or in those in which 
marked intracystic tension has been present, the investing epithelium 
is flattened or may be largely absent. The walls of the cysts are rich in 
blood-vessels, and are composed of unstriped muscle and fibrous connec- 
tive tissue. Only rarely can gonococci be recovered from the contents 
of the cyst, for prolonged encapsulation tends to destroy this organism. 

' Kleinwachter: Zeit. f. Geb. u. Gyn., vol. xx.xii, p. 191. 
- Wiener, S.: Amer. Jour. Obst., February, 1912, p. 243. 
' Dartigues: Paris Chirurg., 1911, vol. iii, p. 565. 


Bartholinitis. — If occlusion does not occur in the duct, and the in- 
fection extends to the gland, inflammatory changes are here set up. 
The gland becomes enlarged, infiltrated with inflammatory products, 
and presents the usual clinical and pathologic characteristics of adeni- 
tis. This stage may become chronic, with the formation of more or 
less connective tissue, so that the gland is easily palpable while in situ 
as a firm, oblong, flattened body. 

Abscess of Bartholin's Gland. — Not infrequently, however, the 
inflammation advances to pus formation, and a Bartholin's abscess 
results. When this occurs, only rarely is the entire gland equally 
involved. As a rule, one or more lobules are affected, and when the 
abscess ruptures or is incised, healing tends to occur without eradica- 
tion of the infection, so that at a subsequent date, often as the result 
of slight trauma or of reinfection with virulent microorganisms, or 
sometimes for no apparent reason, suppuration develops in other 
lobules. The history of a number of abscesses occurring in this lo- 
cality and extending sometimes over a considerable period of time is 
pathognomonic of this condition, and is due to suppuration first of one 
lobule and then of another. The entire gland must be removed if 
a permanent cure is to be effected. Macroscopically, the abscesses 
appear as small, ovoid or round, purulent collections, rarely larger 
than a bantam's egg, and more often about the size of an English 
walnut. The abscesses are situated rather deeply, and involve the 
lower portion of the labia, extending backward toward the perineum. 
Sometimes there is considerable swelling and induration surrounding 
the abscess, whereas at other times there is comparatively little. In 
some pus may be squeezed out of the duct. The walls are, as a 
rule, thick, and the lining not infrequently presents a septate appear- 
ance. The contents consist of moderately thick, yellowish or green- 
ish pus. which is often blood stained. 

Hishildi/i/. The gland and the surrounding tissu(> are infiltrated 
with acute or subacute infiannnatorj' products. The epithelium of 
the gland presents the usual inflannnatory cluinges. The blood- 
vessels are engorged, and freciuently the inflannnatory changes are 
found following along the course of the lymphatics. The pus in these 
abscesses contains gonococci, and not infrecjuently other micnxirgan- 
isms are present; indeed, some writei's assert that mixed infection is 
always present in supi)urati\'e in'occsscs of tills locality. 

Condylomata acuminata, or venereal warts, of gonorrheal origin, 
arc the result of irritation produced by the more or less constant 


bathing of the parts with the leukorrheal discharge. They are pap- 
illary outgrowths that appear on the external genitaUa and occasion- 
ally on the vagina or cervix. The tumors may spring from the per- 
ineum, labia majora or minora, or other adjacent structures. The 
growths vary in size from those of microscopic dimensions to those the 
size of a man's fist or larger. The history of an unusually extensive 
case has recently been reported by Rassegna.^ Multiple growths are 
the rule, and tumors of various sizes are usually present in the same 
ease. The tumors are composed of localized hypertrophies of the outer 
layers of the skin, and are whitish, pinkish, or purplish, wart-like, 
cauliflower-shaped masses, sometimes distinctly pedunculated, and in 
other instances springing from a broad base. The tumors originate as 
discrete outgrowths, but frequently they coalesce. The surface of the 
tumors and the surrounding skin are bathed by a thin, irritating, 
offensive discharge. Condylomata acuminata of gonorrheal origin 
usually possess a distinctly pointed apex, in contradistinction to syphi- 
litic condylomata, which are flattened, and only rarely tend to become 
pedunculated. Gonorrheal condylomata acuminata, when situated 
within the vagina, are often flattened as a result of pressure, and fre- 
quently present a somewhat macerated appearance. As a result of 
the irritating discharge, the cutaneous surface surrounding the ex- 
crescences is often reddened. 

Histology. — The tumors are composed of hypertrophies of the outer 
layers of the skin, the papillse forming the chief constituents of the 
growths. They are moderately well supplied with blood-vessels, and 
upon their vascularity and the thinness of the outer layers of epithe- 
lium depend, to a large extent, their color and the amount of discharge 
they produce. The connective tissue surrounding the tumors gen- 
erally presents a moderate degree of chronic inflammatory reaction. 

The vagina is lined by a modified skin and normally contains but 
few glands. Cullen, v. Preuschen, Hennig, and others have demon- 
strated conclusively the presence of glands in the vaginal hning, and 
have also proved their relative scarcity. In the young the outer layer 
of the stratified squamous epithelium is ill developed, and this fact 
accounts, to a large extent, for the frequency of acute vaginitis in 
children. As puberty is approached the epithehal layer becomes 
thicker and more dense and an attempt is made toward the formation 
of an outer horny layer, such as is found in the skin proper, and, as a 
result, acute vaginitis during active sexual life is infrequent. At the 

' Rassegna: Jour, d'obst. e ginec, Naples, 1911, vol. xx, 217. 


menopause atrophic changes occur, and doubtless partially explain 
the greater susceptibihty of the vagina to infection at this tinie. 

During the acute stage the vaginal lining is reddened, swollen, 
edematous, and bathed in a creamy, yellowish, purulent discharge, 
which may be blood-streaked. The normal acid reaction of the vagi- 
nal secretion is diminished or may even be alkaUne. In the chronic 
stage, especially in the young, the vaginal mucosa presents a granular 
appearance, due to localization of the inflammation to various groups 
of papilla?. Ulcers or small excoriations are not infrequent, and when 
of gonorrheal origin, are often present in the vaginal vault. Gon- 
orrheal vaginitis cannot with certainty be distinguished by the macro- 
scopic appearance from other forms of inflammation. In long-con- 
tinued cases vaginitis condylomatosa may be present. The growths 
are much less frequent, of smaller size, and are more discretely dis- 
tributed than when occurring on the external genitalia. 

Histology. — The various layers of the vaginal mucosa are swollen 
and infiltrated with inflammatory products. In chronic cases the in- 
flammation often shows a tendency to localize in certain groups of 
papillae in the subepithelial tissue. In some instances the epithe- 
lium may desquamate, producing small ulcers that may extend to 
the underlj'ing connective tissue. Immediately beneath the layer of 
stratified squamous epithelium is usually found a well-defined zone of 
inflammatorj' reaction, characterized by an infiltration of small round- 
cells, polymorphonuclear leukocytes, serum, and congested capil- 
laries. Small round-cells and polj^morphoimclear leukocytes are also 
often present in the protective epithelium. 

The infection originates at or just within the external urinarj' 
meatus. During the acute stage the mucosa of the external meatus is 
swollen and reddened, and may be found protruding a short distance 
from the urethra. Further examination reveals the fact that the 
mucosa of the canal is inflamed. INIilking the urethra jiroduces a con- 
siderable quantity of creamy yellowisli pus, which contains typical 
gonococci in large numbers. The urethra itself is tender, and may be 
felt as a more or less indurated l)and lying beneatli the vaginal nuicosa. 
As the disease becomes chronic the discharge diminishes, becomes 
milky or mucopurulent in character, and in some cases disappears 
almost entirely. The gonococci are fewer in number, and under 
ordinary circumstances it may be impossible to obtain typical micro- 
organisms. The mucosa of the urethra may be slightly thickened or 
may a{)pear normal. Skene's and Schiillcr's glaiuls are, however, 


nearly always reddened and prominent, and upon pressure a small 
amount of pus can usually be extruded. The urethra at this stage 
may feel normal to the examining finger, or a certain amount of peri- 
urethral infiltration may be present. The latter is generally the case 
in long-standing chronic cases. Abscesses may form in Skene's, 
Schiiller's, or in any of the mucous glands of the urethra in either the 
acute or the chronic stage. The abscesses are usually on the floor of 
the anterior portion of the urethra, and tend to bulge into the vagina. 
More or less complete evacuation of the contents of the abscess into 
the urethra can often be accomplished by pressure through the vagina. 
As a result of long-standing inflammation the mucous glands some- 
times become obliterated, and under such circumstances these struc- 
tures can often be felt immediately beneath the urethra as hard, 
indurated bodies. A caruncle may develop. 

Histology. — Specimens of urethritis are rarely seen in the labora- 
tory, but when observed, are found to present the usual evidences of 
inflammation, the histologic picture varying according to the portion 
of the urethra examined and the stage of the disease. The inflamma- 
tory changes are most persistent in the glands in the anterior portion 
of the floor of the urethra. 

Gonorrheal infection of the cervix is extremely frequent, and, ac- 
cording to Menge,^ is found in about 80 per cent, of all acute and in 
95 per cent, of all chronic cases. The gonococcus exhibits a marked 
predilection for columnar epithelium, and a comparative protective 
influence is exerted by squamous epithelium, especially the fully de- 
veloped squamous epithelium of the adult. The portio vaginahs is 
normally covered by multiple layers of stratified squamous epithelium, 
and is, therefore, rarely if ever primarily involved. Anatomic re- 
search has demonstrated the fact that the squamous epithelium usually 
extends upward in the cervical canal to about the external os. Cul- 
len,^ Ruge,^ and others have shown that this is a variable point. In 
some cases the squamous epithelium extends upward nearly to or 
even above the internal os, whereas in other cases the point of junction 
of the two types of epithelium is considerably'^ outside the external os. 
From the vaginal wall to the external os the squamous epithelium grad- 
ually thins out until, at the point of junction with the cyhndric epi- 

' Menge, K.: llaiulbuch der Geschlechtsk., Vienna, 1910. 
■ Cullen, T. S. : Cancer of the Uterus, 1900, p. 17. 

2 Winter, G., and Ruge, C. : A Text-book of Gynecological Diagnosis. Translated 
after third revised edition, Philadelpliia and London. 


Fig. 2. — Endocebvicitih. 
The section has been takc-u through the mucosa of the cervical ranal. The surface epithehum is, for 
the most part, desquamated. The superficial layers of the mucosa are infiltrated with atx inflammatory exudate. 
!ii the deeper portions of the glands the epithelium is somewhat degenerated, and a well-<lefined periglandular 
inflammation is present. The pathologic changes are, however, most marked near the surface ( X 50). 


thelium, it is, as a rule, not more than half as thick as at the vagino- 
cervical junction. In some cases the cylindric epithelium is of a 
slightly papillary character, and extends outward over the portio — 
the so-called congenital erosion. Theoretically, therefore, women in 
whom the squamous epithelium is thin; those in whom the squamous 
epithelium extends only to the external os; and those in whom the so- 
called congenital erosions are present, should be more susceptible to 
gonorrheal cervicitis than those in whom the squamous epithelium is 
thick, and in whom it extends deeply into the cervical canal. Gon- 
orrheal infection tends to locaUze itself in the true mucosa of the cer- 
vical canal, and if extension upward occurs, this takes place at a men- 
strual period, or during or immediately subsequent to the emptying of 
a pregnant uterus. In other words, in the great majority of cases the 
infection originates as an endocervicitis, the chief symptom of which 
is a cervical leukorrhea produced by a hj^persecretion of the cervical 
glands incident to the inflammation. As a result of swelling and hy- 
peremia of the mucosa of the canal, not infrequently a portion of this 
will project beyond the external os, and in chronic or severe cases the 
inflammation itself may involve the adjacent squamous epithelium of 
the portio, so that on examination the external os appears as a bright- 
red spot surrounded by an infiltrated, granular area of more or less 
limited extent, and bathed in an abundant thick mucus or mucopuru- 
lent discharge. Gottschalk' explains the presence of cylindric epi- 
thelium in the portio — the so-called "erosion" due to gonorrhea — by 
stating that the glands found in these inflammatory processes are true 
ectopic cervical glands. The normal stratified squamous epithelium 
of the portio is pushed away by extravasated blood, by a copious in- 
filtration of small round-cells, and sometimes by the rupture of an 
underlying retention cyst. The denuded surface of the portio becomes 
rapidly covered by the mucosa from the canal, and by ectopic cervical 
gland epithelium from glands that open upon the denuded area. In 
some in.stances newly formed stratified squamous epithelium is pushed 
off by an extension of the mucosa of the canal. Naturally, the picture 
varies (juite markedly in different individuals and in the nuUiparous 
and the nuiltiparous. Retention cysts, formed from tlie cervical 
glands and varying in size from a few millimeters in diameter to the 
size of a pea or even larger, are often present. True macroscopic 
erosions of gonorrheal origin are extremely rare. 

Hist()lo(/y. — The chronicity of gonorrheal cervicitis can be entirely 
explained by a study of the histology of this organ. In the sexually 
mature individual the cervical canal is lined by high cylindric ('jjithe- 

'Collsclialk, S.: Ilrit. Med. .lour., October 22, 1910. 


Hum, a type of tissue peculiarly susceptible to gonorrhea. The secre- 
tion of the canal is weakly alkaline in reaction. The walls of the canal 
are irregular, and for the most part are composed of heaped-up mu- 
cosa, known as the arbor vitse and the pUcse palmatEe. The mucosa 
itself contains numerous mucous glands, which vary from small crypts 
to those suggesting the racemose type. The entrance to many of 
even the large glands is very small (the flask-Uke glands), whereas 
others are tubular in character or undergo repeated branching — all 
points that favor the continuance of the infection. The cervical glands 
are the lurking-place of the gonococcus, and, owing to their nature, 
offer peculiar protection against the ordinary forms of treatment. 
As the result of gonorrhea, the entire mucosa becomes edematous, 
infiltrated with inflammatory products, and the openings of the glands 
become even more contracted. As the infection becomes subacute 
or chronic, the stroma of the mucosa in many areas assumes more or * 
less its normal appearance, the inflammation usually persisting as a 
periglandular reaction, characterized by an infiltration of small round- 
cells. Not infrequently a narrow zone of small round-cells, occasion- 
ally leukocytes, free blood, serum, and engorged or newly formed 
vessels, is present immediately beneath the squamous epithelium about 
the external os. As a result of inflammation some of the gland-open- 
ings become occluded, and small retention cysts (ovula Nabothi) occur. 
These are lined by cylindric epitheUum, which in many cases, owing to 
infraglandular pressure, is greatly flattened. The cylindric epithelium 
of the canal not infrequently shows metaplastic changes, and even 
areas of reduplicated layers of more or less typical squamous epithe- 
lium may be observed. Metaplasia of the surface epithelium is more 
frequent than that of the glandular. A certain amount of cervical hy- 
pertrophy usually results from long-standing inflammation. The in- 
flammation is, as a rule, moderately superficial. 

These conditions invariably result from an endocervicitis. The 
extension from the mucosa of the cervix to that of the body of the 
uterus occurs with but few exceptions either at a menstrual period or 
shortly following the emptying of a pregnant uterus. While gonorrheal 
endocervicitis tends to become chronic and exhibits Uttle or no dis- 
position to spontaneous cure, gonorrhea of the corporeal endometrium 
in many cases does go on to resolution. This may possibly be ac- 
counted for by the excellent blood-supply and drainage of this locahty. 
Not infrequently an active inflammation of the endometrium is kept | 
up by a constant reinfection from the leaking uterine end of a pyosal- 



■\ ^^ 

Fig. 3. — Endometrium During the Postmenstrual Period. 
The glands run a straight course, perpendicular to the surface. The lumen of each gland is extremely 
and empty (C. C. Norris and F. E. Keene, Surg,. Gyn., and Obst., January. 1909, pp. 44-54). 





Fig. 4. — Endometrium Dukino the Intekval. 
Tin- upper portion of the stroma shows odcmu. The luminu of the gland.'* nn; tlUtinrtlv wider thiin lit 
thr prcceditiK rttuge. und have aaaumed the corlwcrew shape. Some of the glaticU contain u thready sub- 
stance, taking the cosin stain (C. C. NorrU and F. E. Keene, Surg., Gyn., and Obst., January, 1009. pp. 

Fig. 5. — Endometrium During the Premenstrual Stage. 
The superficial compact and deep spongy layers are easily recognized. The glands ar 
and their lumina are still wider than those of the interval. Many of the glands contain i 
and F. E. Keene, Surg., Gyn., and Obst., January, 1909, pp. 44-54). 

irregular in shape 
lucus (C. C. Norris 



pinx. Indeed, well-marked cases of chronic corporeal endometritis 
are comparatively seldom observed, except in conjunction with tubal 
infection or abortion, and even in the presence of well-marked ad- 
nexal lesions the endometrium is often comparatively normal. Prior 
to the researches of Adler and Hitschmann,' which were subsequently 
confirmed by the work of Keene and the author,- as w'ell as by other 
observers, many of the physiologic changes incident to the normal 
menstrual cj^cle were viewed as pathologic, and, as a result, endome- 
tritis was frequently diagnosed when no inflammatory change of any 
sort existed. Furthermore, the classification of endometritis was 
greatly compUcated by such qualifying terms as glandular, interstitial, 
polypoid, fungoid, etc., which were in manj^ instances, at least, merely 
phases of the menstrual cycle. Thus, if the endometrium to be ex- 
amined has been removed a few days prior to menstruation, the glands 
would naturally be large and prominent, and a glandular endometritis 
would be diagnosed, whereas if the tissue chanced to be examined in 
the postmenstrual period, it was often thought to be the seat of an 
interstitial inflammation. 

Albrecht^ divides endometritis into three forms — acute, chronic, 
and specific (syphilitic and tubercular). The author has found this 
classification entirely satisfactory. This question is not, however, 
entirely settled. Hitschmann and Adler"* believe that there may be a 
glandular hyperplasia, but that it has nothing to do with inflammation, 
and that the term "endometritis glandularis hyperplastica " is a mis- 
nomer. They assert that, even in the early stages of inflammation, 
a diagnosis of endometritis is justifiable onlj'' when the plasma cell is 
present. Buttner'' considers the plasma cell a certain criterion of 
inflammation and that nothing else is so positive. He, however, be- 
lieves an abundant infiltration of leukocytes may be accorded con- 
siderable importance. Mittelmann,''' while conducting a research sug- 
gested by Veit, came to the conclusion that there may be an acute 
or a subacute endometritis in which no plasma cells are present, but 
that in chronic endometritis these cells can alwaj^s be observed. This 
observer concludes that the diagnosis of endometritis depends upon 
the microscopic finding, and cannot be made from the cUnical symp- 
toms. Other authors claim that the presence or absence of the plasma 

' Adler and Hitschmann: Monats. f. Geb. u. Gyn., vol. xxvii, No. 1. 

' Norris, C C, and Keeno, F. 10.: Surg., Gyn., and Obst., January, 1909, p. 44. 

' Albrechl: Monats. f. G(>b. u. Gyn., 1911, vol. xxxiv, p. 397. 

• Hitschmann and Adler: Miinch. mod. Woch., 1909, No. 41, p. 2130. 
» Buttner: Miinch. mod. Woch., 1909, No. 30, p. 10,')2. 

• Mittelmann, C: Miinch. med. Woch., 1910, No. 14, p. 703. 


cell is of little significance. Albrecht' declares that in the examination 
of 130 specimens of curetings and the endometrium of 15 cases in 
which the uterus had been removed, in only 5 per cent, were plasma 
cells found. 

It is certain that the physiologic changes incident to menstruation 
continue, sometimes more or less modified, in cases of endometritis. 
It is also certain that some cases of endometritis exhibit a tendency 
toward the so-called glandular form, whereas in others the glands are 
contracted and the stroma is condensed entirely apart from the 
changes incident to menstruation. These facts, while admitted by 
Mittelmann,= are explained by her on the ground of a preexisting hy- 
perplasia or atrophy. Ellerbroeck,' however, after examining the en- 
dometrium of 110 cases of actual endometritis, in all of which the acute 
attack had subsided prior to the removal of the endometrium, concludes 
that Hitschmann and Adler are in error when they deny absolutely the 
existence of a glandular form of endometritis. Frank" also states that 
glandular hypertrophy and hyperplasia may be due to inflammation, 
as well as to ovarian influence. The author's experience is that glan- 
dular, and more particularly interstitial, changes of sufficiently pro- 
nounced characteristics to warrant a diagnosis do occur as the result 
of inflammation, and that while it has nearly always been possible to 
demonstrate the plasma cell in both acute and chronic cases, he con- 
siders it of great diagnostic value, but is of the opinion that its presence 
is not essential , for the diagnosis of endometritis. While the presence 
or absence of the plasma cell is a valuable aid to the diagnosis of en- 
dometritis, the entire question should not, however, rest upon this 
point. To demonstrate the presence of plasma cells certain special 
fixing and staining reagents are necessary. As a further proof that 
the glandular and interstitial changes are not entirely dependent upon 
the menstrual cycle, it may be stated that it is no uncommon experi- 
ence to find, in the same endometrium, some areas presenting pro- 
nounced glandular hypertrophies, whereas in others atrophic or in- 
terstitial changes may be observed. However, in many cases no 
inflammatory glandular changes are present, and, indeed, only rarely 
are these sufficiently well marked to merit the term glandular or inter- 
stitial endometritis. This is an additional argument against the em- 
ployment of the terms glandular, interstitial, polypoid, etc., when re- 
ferring to inflammations of the endometrium. 

' Albrecht, H.: Munch, med. Woch., 1910, No. 23, p. 1260. 
' Mittelmann, C: Mtinch. med. Woch., 1910, No. 14, p. 763. 
'Ellerbroeck: Zentralbl. f. Gyn., 1909, vol. .\xxiii, p. 682. 
* Frank, R. T.: Amer. Jour. Obst., February, 1912, p. 207. 





> C 

Via. 0.— The Decidda or In 
H, Hpoiigy layer; C, iruisclt' (C. C. li>^iii.i mn 
uiiry, )!)()9, pp. 44-51). 

nml F. E. Kceiio. tSurg., Gyn,. aiicl I II>mI., 

d»|', f 


® 1^ 

Fig. 7. — Glandular Epithelium During 


The cells are low and narrow, and the 
nucleus occupies a large portion of the cell. 
The lumen of the gland is very narrow and 
completely empty (C. C. Norris and F. E. 
Keene. Surg., Gyn., and Obst., January. 1909, 
pp. 44-54). 

Fig. 8.— Glan-dular Epithelium During the In- 
The cells have become higher and broader, and at 
.1 -^how an inner granular and outer homogeneous zone. 
The nuclei are well stained and are situated at the base 
of the cells. The lumen of the gland is dilated and 
contains a thready material (C. C. Norris and F. E. 
Keene. Surg., Gyn.. and Obst., January, 1909). 



Fiti. '.I.— Glaxdi-lar the Latk Premenstrual Stage. 
The individual cells are indistinctly differentiated from one another. The cells have become much 
broader, and their inner contour irregular. In some areas (.4) the inner aspect of the cells appears broken, 
with discharge of their contents into the lumen of the gland. .\t B there has been a proliferation of the cells; 
C. mucus (C. C. Norris and F. E. Keene, Surg., Gyn., and Obst., .lanuary, 1909). 


Since the plasma cell is now recognized not only as an indication of 
endometritis, but is by some authorities considered to be of much 
significance in the differential diagnosis between gonorrhea and other 
forms of infection, not only in the endometrium, but also in the adnexa, 
a more detailed description may not be out of order. 

By Mallory's eqsin-methylene-blue stain the lymphogenous cells 
maj' be demonstrated particularly well, and their identification, even 
with the low power, is easy. By Schridde's' method of osmic acid and 
acid fuchsin stain, certain granular elements in the protoplasm sur- 
rounding the nucleus can be beautifully shown, not only in the plasma 
cell, but also in the lymphocytes and Ij'mphoblasts. Unna-Pappen- 
heim's methyl-green stain also gives excellent results. 

Schridde's method for staining cells is as follows: 

1. Within a few minutes of removal place tissue in Orth's fluid, warmed 
to 35° C, and keep in the incubator at this temperature for twenty-four hours. 

2. Miiller's fluid at room temperature, twenty-four hours. 

3. Running water, twenty-four hours. 

4. Distilled water (many changes), six hours. 

5. One per cent, aqueous solution of osmic acid, in the dark, twentj^- 
four hours. 

6. Place sections in ascending alcohols (70 per cent., 80 per cent., 95 
per cent., and absolute), allowing them to remain in each for about twelve 

7. Chloroform (pure), four hours. 

8. Equal parts of chloroform and ])araffin (55° F.) over tlic oven, 
twelve hours. 

9. Paraffin (.50° to 55° F.) liaths, in the oven (two changes), two hovu's 

10. limbed (60 paraffin) and cool quickly in cold water. 

11. Cut thin sections (1 to 2 /i). 

Staining is as follows: 

1. Place sections in xylol (two changes), five minutes each. 

2. Absolute alcohol, 95 per cent., and SO per cent., three minutes each. 

3. Wash in distilled water. 

4. Stain in warmed anilin-water acid-fuclisin (acid-fuciisin, 20 grams; 
anilin-water, 100 c.c.) over night or from two to twenty-four hours. 

5. Drain off and differentiate in the fullowing solution: 

Saturated alcoholic solution of picric acid I jiarl 

Twenty per cent, alcohdl 7 p.arts 

until the section lieccjnies a clear, yellowisli-red color, wliicli will lake about 
thirty minutes or a little longer. 

' Siliiiilric: MiiMch. incfl. Wocli., KKIS, No. •.'(), 


6. Dehydrate in 95 per cent, alcohol; then in absolute for a few seconds, 
clear in xj'lol and mount in xylol balsam. 

Result: Neutrophihc granules, brownish red; eosinophilic, blackish red; 
plasma-cell granules, brick red; mast-cell granules, grayish black; basophilic 
granules, unstained, but easily distinguishable; bro^aiish-red granules in the 

The plasma cell is about twice the size of a lymphoid cell, and pos- 
sesses a comparatively large amount of basophilic protoplasm. The 
cell outline is usually polyhedral and generally irregular, and often 
shows a pale staining area surrounding the nucleus. The nucleus is 
moderate in size, and, owing to the large amount of chromatin pres- 
ent, stains deeply. It usually presents a circular or wheel-like ap- 
pearance. Gurd^ has drawn attention to the curious appearance of 
the nucleus observed in some sections ; the appearance does not in the 
least resemble the typical "Radkern," but shows two narrow, crescent- 
shaped masses of chromatin upon each of the two sides of the nucleus, 
as if the chromatin had arranged itself entirely over the surface of the 
nucleus, leaving no meshwork of chromatin material within the latter's 
substance. The origin of the plasma cell is still somewhat in doubt. 
Unna- believed that the cell developed directly from fibrous tissue. 
Marchand^ suggested that it might be derived from specially differen- 
tiated adventitia cells. Joannovics^ asserts that he believes that the 
plasma cell is a derivative of the tissue lymphocyte, which, for the 
most part, is developed from adventitial elements. Marschalko^ and 
Gurd" believe the cell to be developed from the lymphocyte of the 
blood or lymph, and this opinion is generally held by pathologists at 
the present day. Schridde^ states that large numbers of Russel's 
bodies are always found among plasma cells. Gurd,* on the other 
hand, declares that in his preparations they were not more numerous 
than in general chronic inflammations. Miller' has carefully studied 
these structures, and concludes that true Russel's bodies develop only 
in plasma cells; that when they are extracellular, they are round, 
refractile, and stain an intense black with Weigert's stain, and that he 
believes them to be a myelin degeneration of the protoplasm of the 

' Gurd, F. B.: Jour. Med. Research, 1910, vol. xxiii; new series, vol. x\'iii, p. 169. 
' Unna: Plasmazellen, Eneyklopaedie der mik. Technik, 1903, p. 1116. 
' Marchand: Der Prozess der Wundheilung, mit Einfluss der Transplantation, Stutt- 
gart, 1910. 

* Joannovics: Cent. f. all. Path. u. path. Anat., 1909, vol. xx, p. 1011. 

' Marschalko: Arch. f. Dermat. u. Syph., 1895, vol. xxx, p. 214. 

' Gurd, E. B.: Jour. Med. Research, 1910, vol. xxiii; new series, vol. xviii, p. 169. 

' Schridde: Munch, med. Woch., 1908, No. 20. 

' Gurd, F. B.: Jour. Med. Research, 1910, vol. xxiii; new scries, vol. xviii, p. 171. 

' Miller, J. W.: Virchow's Archiv, 1910, vol. 199, p. 482. 



Fig. 10. — Tyi'Ical Opitz-Gkbhard Glands, Showing Fern-like Ingrowths ok Prouferatino Epitheuum. 

Nole that the general character of this gland is similar to that of the premenstrual stage, only in this case the 

chanEcs are more advanced (C. C. \orris and F. F.. Kccnc, Surg., Gyn., and Obst.. .January, IflOD). 



:f I 

In;. II. — !<TR(1.«A ('eL1.«. 

I, .''Iroiiin cells in poatmenstrual stane. 2, Stroma cells during interval, showing colleclion of small 
round-cells. ;j. Stroma cells during late premenstrual stage. 4, Deciduu cells (C. C. Norris and F. K. Keene, 
Surg., Gyn., anil Olist.. .lanunry, lUOdi. 


plasma cell. Miller does not believe that Russel's bodies result from 
hyaline degeneration, and warns against confounding them with 
vacuolated degeneration of the plasma cell nucleus, or with colloid 
produced by epithelium. 

Gonorrheal endometritis cannot positively be distinguished either 
macroscopically or microscopically from manj' other forms of infec- 
tion of this locality, except by the demonstration of the specific micro- 
organism in the tissue or exudate. This is usually easj' in acute cases, 
but often difficult after they have become chronic. During the acute 
stage the endometrium is thickened, reddened, edematous, and hy- 
peremic, and is bathed in a moderately thin, punalent discharge. 
Areas of subepithelial ecchymosis are often observed, and it frequently 
happens that the entire mucosa is not equally involved. The surface 
often presents a granular appearance. During the chronic stage the 
mucosa may present an appearance differing but little from that of 
the normal endometrium. It is, however, usually more or less thick- 
ened, although atrophic changes sometimes follow subsidence of an 
acute process. Occasionally the surface presents an irregular, poly- 
poid contour, and granular-like areas may be observed. 

Histology. — In studying the endometrium the changes incident to 
the normal menstrual cycle must always be borne in mind, for although 
the normal changes may be modified as a result of inflammation, they 
should by no means be overlooked. Data giving the date of the last 
menstrual period, the regularity and frequency of the periods should 
be supphed to the pathologist. In gonorrheal endometritis the most 
marked changes are usually found in the superficial portions of the 

Acute endometritis is characterized by swelling, edema, and hy- 
peremia of the mucosa. The surface may present areas of granulation, 
whereas in other parts the surface epithelium may be proliferated and 
more or less atypical in size, shape, and staining properties. The 
glands ma J' show varying changes; in some cases they are normal, 
whereas in others they are enlarged or may be cystic. In some in- 
stances, as a result of inflammatory exudates in the stroma, the glands 
may appear to be contracted. The glandular epitheUum is rarely 
proliferated or desquamated, but usually shows evidences of a well- 
marked inflammatory reaction. The stroma is infiltrated with serum 
and polymorphonuclear leukocytes, and often contains free blood. 
The stroma cells are edematous, and may stain irregularly or imper- 
fectly. The blood-vessels are congested. Generally the myometrium, 
for a greater or less dejjth immediately luulerlying the mucosa, is in- 
filtrated with acute inflammatory products. The areas of infiltration 


are often observed surrounding a blood- or a lymph-vessel, and follow- 
ing the course of the latter through the myometrium for some distance. 

Chronic Endometritis. — During the chronic stage the most marked 
pathology is usually found in the superficial portion of the endome- 
trium. The surface epithelium is flattened, and in some areas may be 
desquamated, whereas in others proliferation and even metaplasia to 
cells resembling squamous epithelium may be present. Runge^ has 
called attention to the fact that in some cases of endometritis the cil- 
iated borders of the surface-cells appear to be more robust and resist- 
ant than in the normal endometrium, and may be recognized in alco- 
holic preparations. Hurdon- has suggested that these metaplastic 
changes are possibly analogous to leukokeratosis of the vulvar mucosa. 
The glands are often enlarged in their deeper portions, and in some in- 
stances, due to occlusion or constriction near the surface, may be cys- 
tic. Owing to the presence of inflammatory exudates in the stroma, 
the glands may be somewhat irregularly arranged, some being close 
together, whereas others are widely separated. The glandular epi- 
thelium presents changes similar to those found in the surface-cells, 
but these are, as a rule, less pronounced. The gland lumina may be 
empty or may contain serum, leukocytes, blood, or epithelial debris. 
Adler and Hitschmann^ assert that in the normal endometrium mucus 
is not present in the corporeal endometrium during the post-menstrual 
or interval periods ; when the endometrium is the seat of an infection, 
mucus is not infrequently observed in the glands, and may be present 
at any time, although it is more frequently observed during the pre- 
menstrual and early menstrual periods. In chronic endometritis the 
stroma is more or less densely infiltrated with inflammatory products, 
and with proper fixing and staining conditions, plasma cells can usually 
be demonstrated. The blood-vessels, which normally consist only of 
endothelial tubes, are often found to possess well-developed muscu- 
lar walls, and may be increased in number. The underlying uterine 
muscle is usually more or less involved in the inflammatory process. 

Metritis. — In gonorrheal infections of the uterus the inflammation 
may be limited to the mucosa or may involve the underlying myo- 
metrium. In severe cases the uterine parenchyma, especially the inner 
layer, is always invaded. In the acute stage the uterus is enlarged, 
softened, and boggy. The normal shape is usually quite well pre- 
served, although a tendency toward broadening of the organ is gen- 

' Winter, G., and Runge; Text-book of Gynecological Pathology, edited by J. G. Clark, 
Philadelphia and London. 

'Hurdon, E., Kelly, H. A., and Noble, C. P.: Gynecology and Abdominal Surgery, 
Philadelphia and London, 1907, vol. i, p. 11.5. 

^ Adler and Hit.srhmann: Monat.s. f. Geb. u. Gyn., vol. xxvii. No. 1. 


The utonis is enlarged, this being especially noticeable in its lateral diameters. The uterine walls are 
thickened, and the musculature appears somewhat coarser than normal. Here and there, projecting from the 
cut surface of the musculature, prominent blood-vessels are observed. The endometrial cavity is normal in 
shape, and the mucoso is but little thickened. The arbor vitte of the cervical canal are unusually prominent, 
and in the fresh specimen were considerably reddened. The tubes have been converted into small pyosnlpinges. 
The ovaries are enlarged and contain retention cysts. On microscopic examination they were founil to jiresenl 
» well-marked peripheral inflammation and some thickening of the capsule. 



I'lc. 1^. — Kndomkticitih and Mkthitim. 
Th." .•ri.| is uboiit normiil in thickncMH. TIk- Murfiirr 
cpitht-liuiii in iiiiK-h fluttriied. Tin- Klands arc noniuil in mimbrr iiiu) 
of the intorvul type. Tlic Klnndular (■pitheliiim also m1iou'» dt'KeniTntivo 
chanK('». but these arc Ic(*h innrki-d than on the surface. The stroma 
is infiltrated with inflammatory products, chieHy plasma colls. The 
underlying musculature also tukes part in the inflammatory reaction. 
This is moat nnirked in the sonc inunedialely vinderlyins the endo- 
metrium, and in many areas appears to follow the course of the blood- 
vessels or lymphatics, Ilyslereetomy was performed about ten days 
after a m.-tistrual periotl had occurred ( X 10). 


erally seen. In the chronic stage the softening is less marked, Init 
there is nearly always some enlargement, especially in the trans\'erse 
diameters. Pronounced cases of gonorrheal metritis are usually 
associated with adnexitis and its accompanying evidences of pelvic 

The gonorrheal inflammation extends from the endometrium to 
the Fallopian tube by direct continuity along the mucosa. At first 
only the mucosa of the tube is involved, but as the disease progresses 
the muscularis and even the serosa are affected, and various lesions, 
such as salpingitis, pyosalpinx, hydrosalpinx, tubo-ovarian abscess, 
or tubo-ovarian cysts, may be produced. With these are associated 
the usual lesions of pelvic peritonitis. At times a suppurative lesion 
will be present in one adnexa, whereas the other may be the seat of a 
hydrosalpinx or a perisalpingitis, or the tube and ovary may be 
normal; in still other cases bilateral pathology may be present. No 
rule can be laid down in this respect, except that the more frequent, 
prolonged, and severe the attacks of pelvic peritonitis have been, the 
more extensive are the lesions likely to be. 

The most frequent pathologic condition produced by a gonorrheal 
infection of the tube is a pyosalpinx. Among 1070 inflannnatory lesions 
of the tubes seen in the Laboratory of Gynecologic Pathology at tlie 
University of Pennsylvania, none of which was associated with neo- 
plasms, there were 425 pus-tubes, 151 cases of salpingitis, 253 hydro- 
salpinges, 184 cases of perisalpingitis, 38 tubo-ovarian abscesses, and 
19 tubo-ovarian cysts. 

Gonorrheal lesions of the Fallopian tubes possess certain character- 
istics that, while not sufficient absolutely to prove the etiology of the 
infection, are pronounced enough in the great majority of cases to 
enable the skilled pathologist to be moderately certain of the type of 
infection present. The fact, as before mentioned, that the gonococcus 
invades the tub(>s by means of continuity of the surface mucosa from 
the uterus, produces certain macroscopic or microscopic pictures that 
are more or less characteristic. Pyogenic microorganisms, such as the 
streptococcus and the staphylococcus, reach the tubes by way of either 
the blood- or the lymph-vessels of the broad ligament, the mucosa not 
being primarily invaded. In these infections ovarian abscesses and 
cellulitis are, therefore, common, while, from the very nature of thc^ 
gonococcal invasion, these structures are less frequently involved, and 
such lesions are generally, if not always, secondary to salpingitis. 
Tuberculosis, which constitutes from 8 to 10 per cent, of all inflaMuua- 


tory tubal lesions, is not infrequently secondary to tuberculosis in 
other parts of the body, and even when primary, usually produces 
a characteristic pathology. Small mihary tubercles scattered over 
the surface of the tube and a tendency toward imperfect closure of the 
abdominal ostium or the visibility of fimbrise after closure of the outer 
end of the tube and cheesy contents are almost positive proof of the 
nature of the infection. The frequency with which the abdominal 
ostium is not completely closed in tuberculous cases is most striking, 
and may, in fact, be said to be almost characteristic of this variety of 
infection. Even when apparently closed, the appearance of fimbrise 
on the distal end of the tube is most suggestive, and is an important 
diagnostic aid even before the removal of these organs. An absolute 
diagnosis of tuberculosis can almost invariably be made with the aid 
of the microscope. Tubal infections secondary to peritonitis, appendi- 
citis, or general peritoneal conditions affect primarily the outer coats 
of the tube, and, as a result, the mucosa is often found to be compara- 
tively free from inflammation. 

Some authors (Pellagatti, Posner, and Joseph^ consider the pres- 
ence of eosinophiles important in the diagnosis of gonorrhea, especially if 
they also appear early in the urethral discharge. Taylor,- by his own 
work and by that of others, has shown that these cells are of little value 
in the determination of the type of the infection. Von Rosthorn,' 
Arthmann,^ and Wertheim* declare that it is impossible to differen- 
tiate gonococcal from other acute tubal infections. ZweifeP writes 
that in gonorrheal infection the tubal epithelium is devoid of cilia and 
is sometimes vacuolated, a condition that is rarely present in septic 
infections. In 1907,^ and again in 1908, Schridde* directed attention to 
certain histologic peculiarities of the Fallopian tube attacked by the 
gonococcus. In the year following Amersbach^ published a paper from 
AschofT's laboratory in which he stated that when the plica of the tube 
showed swelling and a profuse infiltration with plasma cells, lympho- 
cytes, and lymphoblasts; when the cellular infiltration of the muscularis 
was composed chiefly of small round-cells, and when not only lymphoid, 
but plasma cells and lymphoblasts were present in the purulent con- 

' Pellagatti, Posner, and Joseph: Quoted by Gurd: Jour. Med. Research, 1910, vol. 
xxiii; new series, vol. xviii, p. 171. 

'' Taylor: Jour. Amer. Med. Assoc, 1907, vol. xUx, p. 1830. 

' Von Rosthorn: Arch. f. Gyn., 1890, vol. xxxvii, p. 337. 

* Arthmann: Virchow's Archiv, 1887, vol. cviii, p. 165. 

' Wertheim: Arch, f. Gyn., 1892, vol. xlii, p. 1. 

« Zweifel: Arch. f. Gyn., 1891, vol. xxxix, p. 353. 

' Schridde: Folia Ifematologica, 1907, vol. iv, p. 608. 

' Schridde: Deutsch. med. Woch., 1908, vol. xxviii, p. 1251. 

' Amensbach: Ziegler's Beitriige f. all. Path., 1909, vol. xlv, p. 341. 

Fio. 14. — Uterus and Adnexa from a Case of Pelvic Inflammatory Disease (actual size). 
The uterus is normal in size. Its anterior surface presents a few adhesions. The tubes have become con- 
verted into pyosalpinges, and are densely adherent to the underlying ovaries. The left adnexa are adherent 
to the posterior and superior aspects of the uterus, and merge with the tube and ovary of the ri(thtside, forming 
an inflammatory mass, the individual constituents of which were indistinRuishable b<'fore operation. For six 
weeks prior to operation this case received palliative treatment. When first observed, theadnexal lesions were 
at least twice their present proportions. 


tents of the tube, the diagnosis of gonorrhea could be made with a 
reasonable degree of certainty. These conclusions were based upon a 
studj' of 75 cases, 34 of which he considered to be of gonorrheal origin. 
In only 7 cases were gonococci actually identified. Miller,' on the 
other hand, considers that the plasma cell is by no means characteris- 
tic of gonorrhea. Gurd,' in an excellent paper on this subject, states 
that although it is impossible to speak definitely of a distinctive his- 
tologic picture of gonorrheal salpingitis, the great preponderance of 
plasma cells over other inflammatory cells, as well as the localization 
of the lesion chiefly in the mucosa and submucosa, is very suggestive 
of the gonorrheal origin of the infection. Gurd's results are drawn 
from a carefullj" studied series of 20 cases, in 6 of which the gonococcus 
was isolated in culture, and although in 5 additional cases the gonococ- 
cus was not isolated, this organism was probably the original exciting 

Heymann^ has investigated 50 cases of pyosalpinx from Veit's 
clinic, with a view to determining whether, in the absence of bacterio- 
logic proof, the histologic appearance can be regarded as a sure indi- 
cation, and finds that, while on the whole his conclusions coincide with 
those of Schridde, he does not regard the numerous plasma cells as in 
themselves diagnostic, but considers that when these elements are 
numerous, arranged in groups in the muscularis, mucosa, and in the 
pus in the lumen ; when lymphocytes are numerous, and when leukocytes 
are few or entirely absent, and when there is a broadening out of the 
plica and an agglutination of their tips, gonorrhea is almost certainly 
the exciting cause. Kronig,^ from whose clinic Schridde obtained his 
material, and Aschoff^ support Schridde's views, whereas iNIenge," 
Walthard," and Miller'' believe that the histologic picture just described 
is not peculiar to gonorrhea, but may be produced by any chronic 
inflammation; they call attention to the fact that plasma cells are by 
no means confined to the genital tract, and are often observed in other 
areas from which gonorrhea can be positively excluded. 

Salpingitis. — During the acute stage the tubes become elongated 
and swollen. As a general rule, the normal shape of the tube is more 
or less preserved, although the organ is often kinked and bent upon 
itself. The surface is congested and vascular, and adhesions which are 
readily broken up are nearly always present. These adhesions are 

' Miller, J. \V.: Arch. f. Gyn., 1909, vol. Ixxxviil, p. 217; also Monals. f. CJel). u. Gyn., 
August, 1912, p. 211. 

'(iuril, v. B.: .Jour. Med. Research, 1910, vol. xxiii; new series, vol. xviil, pp. 151-184 
' Hoymann: Zeit. f. Geb. u. Gyn., 1912, vol. Ixx, No. 3. 

•Kronig; .Monats. f. Ocb. u. Gyn., AuKusl, 1912. ' .\schoff: Ihid. 

•Mongo: Ihid. 'Walthard: Ihid. 'Miller: Ilnd. 


usually more numerous on the distal part of the tube, since this por- 
tion is nearer the abdominal ostium, through which infectious material 
is often being extruded, and also because in the proximal portion of 
the tube the walls are thicker and the lumen smaller, containing less 
mucosa to be attacked. On section, the walls of the tube are found to 
be soft, congested, and edematous. In the lumen the picture varies 
according to the portion of the tube examined. The mucous folds are 
reddened, swollen, and bathed in a purulent or seropurulent exudate. 
If the disease tends to become chronic, without closure of the external 
abdominal ostium, the adhesions on the surface become more dense 
and less vascular. The tube is often bent upon itself, especially in 
the outer half. In some cases the tubes are but little enlarged, but 
more often the contrary is the case. At this stage the walls are mod- 
erately firm, due to the increase in fibrous connective tissue. 

Histology. — During the acute period the greatest inflammatory re- 
action is noted in the mucosa, and in the earliest stage it is entirely con- 
fined to this layer of the tube — an endosalpingitis. During the chronic 
stage there is always more or less involvement of the muscularis. The 
various coats of the tube are infiltrated with acute or chronic inflam- 
matory products, varying with the stage of the disease. The surface 
epithelium presents evidences of inflammation, but is rarely desqua- 
mated or proliferated. With proper staining, large numbers of plasma 
cells, together with a varying number of Russel's bodies, can be de- 
tected. The inflammatory products tend to extend through the mus- 
cularis along the lymph- and blood-vessels, and groups of small round- 
cells or polymorphonuclear leukocytes, according to the stage of the 
infection, are seen. In cases of salpingitis the lumen is seldom mark- 
edly dilated, and in sections prepared in the ordinary manner it rarely 
contains much pus. In rare instances a specimen will be seen in which 
the distal portion of the tube will be comparatively normal, or may be 
the seat of a moderate degree of inflammation, and in the intramural 
portion a well-defined, more or less localized abscess is present. These 
abscesses are usually not large, and generally drain directly into the 
uterine cavity. The etiology of this condition cannot be determined 
positively, but in the three cases seen by the writer the suppuration 
appeared in a tube the seat of an old salpingitis, and hence the sugges- 
tion is offered, and indeed it was practically proved in one specimen, 
that during a previous attack ot salpingitis the tube lumen was occluded 
at about the inner end of the isthmus, and that a reinfection, perhaps 
with more virulent microorganisms, occurred from the uterus, which, 
owing to obliteration of the lumen at this point, resulted in the forma- 
tion of an abscess localized to the cornua of the uterus. Although 


I his specimen was rt 
larged, much bent upon i 
fimbria are greatly awolh- 

Fio. Iti. — Acute Gonokhhcal SALi"i.\uiTi». 
■ci durinK the early stage of the disease. The tube is somewhat unifc 
and presents nurnerniis adhesions. The abdominal ostium is pjitulo 
everted. On niilkimr tlic riili.-. pns ould he expressed thronpli both e 

^— .' •^^' 



^^' lE 








oil f 




V \'iV 

.ijMitt.^ *<^-j4fei^-*»'^ 


The section has been taken through the ampulla of the tube The museularis is thin and contains numer- 
ous areas ot inflammatory infiltration. The mucous folds are gracile, and their epithelium is somewhat flattened 
and degenerated. But few pseudo-glands are present. On macroscopic examination a little pus could be seen 
in tlie tube. The abdominal ostium was open, although somewhat contracted (X 16). 


occurring chiefly within the uterine musculature, these abscesses 
should by no means be classed as intramural uterine abscesses. They 
are strictly tubal in origin. 

Pyosalpinx. — This is the usual termination of a salpingitis, but 
may occasionally result from a secondary infection of a hydrosalpinx. 
The actual method of closure of the external abdominal ostium is still 
somewhat in doubt. Doran,^ Kleinhaus,- Opitz,^ Ries,^ and Young^ 
have devoted papers to a description of the manner of closure of these 
tubes. The last-named observer summarizes the various theories as 
follows, dividing them into two classes: Class 1 includes those theories 
that explain the process as being due to an increase in the total 
length of the tube-wall, which, by expanding in an outward direction, 
becomes projected beyond the tubal fimbrise. According to the theory 
of Doran,'' and Kleinhaus,^ the increase in length is dependent on 
swelling and increase in the substance of the tube-wall, associated with 
salpingitis, etc. According to Ries,** the gliding outward of the "peri- 
toneal ring'" over the fimbriae is rendered possible by the fact that the 
walls become loose and redundant subsequent to the collapse of a dis- 
tended tube. In Class 2 are included the theories of Opitz^ and Young; 
the first explains the process as due to a retraction of the muscularis 
and mucosa of the tube within the serous coat, and the latter^" claims 
that the gliding process involves only the mucosa and inner coat of 
the muscularis. The so-called perimetritic closure of Doran" is ex- 
plained by the matting together of the fimbriae by inflanunatory ad- 
hesions without preliminary recession. The latter obviously rarely 
occurs in gonorrhea. In many instances the intramural portion of 
the tube i)rol)al)ly becomes occluded somewhat earher than does the 
external abdominal ostium. This occlusion is the result of agglutina- 
tion of the mucosa. In some cases this becomes permanent, whereas 
in others leakage occurs at irregular intervals. In some specimens the 
occlusion is largely induced mechanically, as the result of a kink or 

Pyosalpinges vary markcdl}- in size. Enormous tul)al abscesses 

' Doran, A.: Trans. London 01).st. Soc, December 4, 1889. 

' Kleinhaus: Veit's Handbuch, first edition, vol. iii, \o. 22, p. 690. 

'Opitz: Zeit. f. Geb. u. Gyn., 1904, vol. Iii, p. 48.'). 

* Hies, E.: Amer. Jour. Obst., August, 1909. 

' Young, .J.: Jour. Obst. and (lyn., Hrilish Knipire, 1910, vol. xvi, p. 307. 

' Ooran, A.: Trans. London Obst. ,Soc., D.'eciiibiT 4, 1889. 

' Kleinhaus: Veit's Hamlburh, first edition, vol. iii, \o. 22. p. (V.X). 

• Rica, E.: Amor. Jour. Obst., .Vugust, 1909. 
"Opitz: Zeit. f. Geb. u. Gyn., 1904, vol. Iii, p. IS."). 

'"Young, J.: Jour. Obst. and Gyn., British Empire, 1910, vol. xvi, p. .{07. 
" Doran, A.: Trans. London Obst. ,S,,c., Diveniber 4, 1889. 


have been described by Richardson/ Genter,^ and others. In Richard- 
son's case the pyosalpinx was at first mistaken for a large myoma of 
the uterus. The distended tube extended upward to the umbiUcus. 
The author has operated in the Philadelphia Hospital upon a case of 
pelvic inflammatory disease in which one pyosalpinx measured 14.75 
cm. in length and had a diameter of 5.5 cm., while the tubal abscess 
on the opposite side measured 13 cm. by 7.5 cm. in diameter. Such 
huge dimensions, however, are extremely unusual. The surface of the 
tube is .covered with dense adhesions, and is sometimes greatly con- 
gested, producing a dark-red color, while in other specimens the tube 
has a yellowish tint. A pyosalpinx is usually of a sausage shape, 
the enlargement being confined chiefly to the distal two-thirds of the 
tube. The tubes may, however, be cylindric or even pear shaped. 
The uterine extremity of the tube may be but little enlarged. Only 
rarely are fimbria; visible. The tubes are frequently bent upon them- 
selves, and more or less thickening and induration are always present 
in the mesosalpinx. The walls of the tube vary widely in different 
cases, the thickness bearing no relation to the diameter of the tube or 
of the lumen. In some small pyosalpinges the walls are thick, whereas 
in those of large size they may be thin, or the reverse may be observed. 
As a rule, the walls are moderately thick— much thicker than when the 
contents are serous. The walls are often friable and edematous. 
The lumina vary in size, the greatest amount of dilatation nearly 
always being found in the ampulla. In recent cases the mucosa is in- 
tact, but in old chronic specimens it may be entirely disintegrated and 
replaced by a pyogenic membrane or by granulation tissue. The con- 
tents of the lumen are, as a rule, moderately thick, and consist of 
yellowish, greenish, or brownish pus. In acute cases gonococci can 
almost invariably be recovered from the pus, either by culture or smear. 
Gurd' beheves that the reason cultures frequently prove negative is 
that the material is generally taken from the free pus, in which locality 
the organisms are often dead, disintegrated, or at least attenuated. 
If the cultures are made from portions of curetings scraped from the 
tubal mucosa and underlying tissue, gonococci can more often be 
demonstrated. As has been stated by Wolff,^ the cytologic examina-, 
tion of the tubal contents is at best unreliable for the diagnosis ofj 
gonorrhea. | 

Histology. — The microscopic picture varies widely in different j 

' Richardson: Johns Hopkins Hosp. Bull., January, 1909, p. 21. 

2 Center, G.: Vrach. Gaz., St. Petersburg, 1911, vol. xviii, p. 829. 

= Gurd, F. B.: Jour. Med. Research, 1910, vol. xxiii; new series, vol. xviii, pp. 151-184. 

* Wolff, A.: Zent. f. Gyn., Leipzig, 1912, vol. xxxvi, No. 49. 


spec- 1 

I'll hi 

into jm ab.sceH» cavity. 
IcinkL-il upon itself. On 
rcplar'c(i by a pyoKCnic 
the sfiit of a mtnihir It^si 


iriirikcn to two-thirds its original si»o. Practirnlly the <.'iiti 
Tho surface presents a number of dense, fan-like adhcsi 
lection, the walls are found to be thickened and cdoniatoiis 
iienibrane. The lumen contains thick, Kroenish-yellow pu 

V tulK-hiisbeenc.iiverted 
jns. The tube is sharply 
anfl the nnicoHti is lar^Eely 
i. The opposite tube was 



Fig. 19. — Section Through an Advanced Chronic Pvosalpin.x. 
The peritoneal coat shows a few adhesions. The muscularis is thioliened, infiltrated i 
products, and contains an excess of fibrous tissue. The blood-vessels e 
the surface epithelium is either desquamated or greatly degenerated. 
have become agglutinated, and the development of small pseudo-glands has resulted. The stroma of the mucos* 
is infiltrated. The most marked pathologic changes are observed near the surface ( X 12). 


ngorged, the mucosa is thickened, and 
In many cases the swollen mucous folds 


specimens. All the coats of the tube are, however, more or less in- 
filtrated with inflammatory products. The mucosa is, as a rule, most 
severely involved. The infiltration is especially profuse about the 
blood- or lymph-vessels. This is particularly noticeable in the mus- 
cularis. As has been stated, the mucosa may be entirely absent; 
more often, however, the phcje are swollen, and the investing epithe- 
lium is more or less degenerated, and frecjuently irregular in size, shape, 
and staining properties. In some specimens the epithelium is intact, 
whereas in others extensive areas of desquamation can be observed. 
It is probable that, under favorable circumstances, areas of desquamated 
epithelium are sometimes replaced by new cylindric cells — the so- 
called plastic epithelium of Menge.^ In many instances, as a result 
of gonorrhea, the tubal epithelium loses its cilia. This is said by many 
authors to be one of the etiologic factors in the production of extra- 
uterine pregnancy. Occasionally metaplasia of the tubal epitheUum 
to cells resembling the squamous type is observed. 

Pseudo-glands, formed by the agglutination of the tips of the mu- 
cous folds, are frequently present. These vary much in size and in dif- 
ferent specimens. In chronic cases the muscularis contains an ex- 
cess of fibrous tissue and is more .or less densely infiltrated with in- 
flammatory products. Large numbers of plasma cells are usually 
observed. These are found not only in the muscularis, but also in 
the mucosa and in the lumen. They are usually arranged in clusters. 
Leukocytes, except in acute cases, are seldom present. Lymphocytes, 
the lymphoblasts of Schridde,^ or large lymphocytes, and also Krom- 
pecher's' mast cells, are often seen. The last-named are moderately 
large cells, which contain coarse, deeply staining basophilic granules, 
and possess a nucleus similar in shape and staining properties to that 
of the plasma cell. Occasionally a few hyaline-hke, homogeneous, 
pink-staining bodies, six or seven times the size of a plasma cell, may 
be observed. These are known as Russel's bodies. Mitosis is fre- 
quent. The serosa is thickened, and a well-developed inflammatory 
membrane of exudate, consisting of a fine fibrous meshwork, in which 
numerous small round-cells, polymorphonuclear leukocytes, or free 
blood may be present, according to the stage of the disease. 

Hydrosalpinx. — This condition, as its name indicates, is a dis- 
tention of the tube with serous or watery fluid. These tubal enlarge- 
ments may lie produced in three ways: (1) By an inflanunation from 

' MniKP, K.: Hand. d. GeschU'chtskrankhciten, Vienna, 1910. 

'Schriddo: Munch, mcd. Woch., 1908, No. 20; also Dcutsch. mod. Woch., 190S, vol. 
xxviii, p. r_'.")l. 

' Kroinpcchcr: Zioglcr's Bcitrage f. all. Path., 1898, vol. xxiv, p. 1().'5. 


within which seals both ends of the tube and allows fluid to accumulate 
within the lumen. The mechanism under these circumstances is very- 
similar to that which produces a pyosalpinx, differing only in the fact 
that the inflammation does not progress to the stage of pus-formation. 
These specimens are known as pseudofollicular hydrosalpinges and 
are the most frequent variety of a gonorrheal hydrosalpinx. As in the 
production of a pyosalpinx, the closure may be largely the result of 
inflammatory stimuli from without the tube — the perimetritic closure 
of Doran.i In this type the chief inflammatory changes are found in 
the outer layers of the tube, and, as a result, the plica are not exten- 
sively involved, except by the changes resulting from intratubal pres- 
sure. These are the specimens which are described in the literature 
as sactosalpinges simplex, and are rarely of gonorrheal origin. They 
often assume a large size. They are generally of puerperal origin, and 
may be due to an infection occurring through the lymph-channels in 
the broad Ugament. Kleinhaus,- in a series of 15 such tubal lesions, 
found that 11 were of puerperal origin. The third method of produc- 
tion of a hydrosalpinx is by the conversion of the pus in a pyosalpinx 
into serous fluid. The transformation of a pyosalpinx into a hydro- 
salpinx is probably of rare occurrence. Menge,' basing his opinion 
on histologic grounds, questions if it ever occurs. Bland-Sutton"* is 
is of the opinion that it occasionally happens. 

A hydrosalpinx may be viewed as a form of tubal retention cyst. 
The affected tubes vary markedly in size, but as a rule they are con- 
siderably larger than are purulent collections. The author saw an 
unusual case in which two tumors, each the size of a fetal head, were 
present. On examination, one of these proved to be an enormous 
hydrosalpinx and the other a tubo-ovarian cyst. Godart^ has recently 
reported an enormous hydrosalpinx which, at first sight, might easily 
have been mistaken for an ovarian cyst. The tumors are generally 
retort-shaped, the swelling starting at the inner portion of the isthmus, 
and rapidly widening out until the outer portion of the ampulla is 
reached. Occasionally the enlargement is spheric. In some instances 
the enlargement occupies the entire extramural portion of the tube, 
whereas in others only the ampulla is increased in diameter. The 
external abdominal ostium may be totally obliterated, or a dimple 
may exist at the site of the tubal closure. The mesosalpinx does not 

' Doran, A.: Trans. London Obst. Soc, December 4, 1889. 
' Kleinhaus: Veit's Handbuch, vol. iii. 
' Menge: Cent. f. Gyn., 1895, vol. xix, p. 799. 
■• Bland-Sutton: Diseases of the Ovaries and Fallopian Tubes, second edition, 1896, pp. 

' Godart, J.: Policlin, Brux., 1912, vol. xxi, p. 88. 


■*'*'',r< -*• 


Fl«. 20. btCTIO.N Tuituuuu a rVUHALI'iXX. 

The surface preHents a few ndheaions. The muaculoris ia thickened, fibrous, and infiltrated with inflam- 
matory products. The niucosn is much thickened. Large numbers of pseudo-absroHsert which vary consider- 
ably in size are seen. The epithelium is generally present, but is markedly flattened and degenerated. The 
Stroma is densely infiltrated with inflammatory products. Considerable pus is present in the lumen ( X l."»). 

Fig. 21.— HvnKMSALi-iNX. 
The tub. ha. been converted into a retort-shaped, thin-walled eystie tumor. The inner third of the tube is 
about normal in dia.uoter. From this point it rapidly widens out and the walls become thin The abdommjj 
ostium is completely closed, and its original location is marked by a small dimple Un section, tnc w. 
found to be thin, the mucosa is smooth, and the lumen contains clear, straw-colored fluid. 



lengthen out proportionately to the increasing size of the tube, and, 
as a consequence, the hydrosalpinx is generally considerably bent or 
even kinked upon itself. The ovary often lies in the concavity of the 
tube. Adhesions are, as a rule, less dense and numerous than when 
the tube contains pus. Sometimes the inner half of the tube is but 
little enlarged, and forms a pedicle for the retention cyst, which may be 
comparatively free from adhesions. These are the types of specimens 
in which torsion is likely to occur. The walls of a hydrosalpinx are 
usually thin, and the lumen is correspondingly dilated. In some speci- 
mens, when the lumen is incised, the remains of the plkse can be dis- 
tinguished macroscopically, whereas in others the lining of the tube 
appeai-s to be smooth. In some instances, owing to the formation of 
pseudo-glands, practically the entire lumen is occupied by what ap- 
pears to be serous cysts, which vary widely in size, and are generally 
more or less concentrically arranged about a minute central cavity— 
the true lumen. The contents of the lumen are made up of thin, 
yellowish or colorless fluid, in which gonococci can rarely be demon- 
strated. Occasionally the fluid is turbid, or may be dark from the 
admixture of blood. In cases of tubal pregnancy hydrohematosal- 
pinges are frequently present in the opposite side, and under such cir- 
cumstances are probably often due to the admixture of blood incident 
to the pregnancy, to a preexisting hydrosalpinx. Hydrohematosal- 
pinges may also result fi'om tubal neoplasm, such as i)apill()nui or 

Hydrops tubae profluens, or intermittent hydrosalpinx, is a condi- 
tion in which the proximal end of the tube is not permanently oc- 
cluded, but when the intratubal pressure reaches a certain point, opens 
out, allowing the tubal contents to escape through the uterus. In 
these cases the stenosis at the uterine end of the tube may be inflam- 
matory or purely mechanical in natiu-c, resulting from a kink or bend 
in the tube. 

Histology. — Micros(!opic examination can, as a rule, determine the 
method of formation of the hydrosalpinx. In the case of hydrosali)inx 
snnplex, the plicsae are free, although they are more or less stunted and 
then- epithelium is free from inflammatory change. The chief in- 
flammatory lesion is situated in the external layers of the tube. In 
a hydrosalpinx that was formerly a pyosalpinx the muscularis 
contains a well-marked excess of fibrous tissue; it is generally 
more or less infiltrated with inflammatory products, while the epi- 
tliehum of the mucosa, and even the stroma, usually presents well- 
defined evidences of a preexisting destructive inflanmiation. In the 
ordmary follicular hydrosalpinx the inllanmiatory reaction is confined 


chiefly to the mucosa, and numerous pseudo-glands, formed by an 
agglutination of the tips of the mucous folds, are present. The epi- 
thelium is comparatively normal, and does not exhibit the marked 
inflammatory changes seen in a case of a converted pyosalpinx. The 
peritoneal surface of a hydrosalpinx usually presents adhesions; the 
muscularis is thin and stretched, due to the intratubal pressure, and 
may be more or less infiltrated with small round-cells, plasma cells, 
lymphocytes, polymorphonuclear leukocytes, and serum. As a rule, 
comparatively few active inflammatory products are present. This, 
however, depends largely upon the form of the hydrosalpinx and the 
stage of the infection. 

Peri-oophoritis. — As a result of gonorrheal tubal lesions, more or 
less infected material escapes into the pelvis and over the ovaries, which, 
from their situation, are particularly prone to be thus contaminated. 
As a result, a peri-oophoritis develops, and the ovary may become 
adherent to the tube, the posterior surface of the broad ligament, the 
omentum, the bowel, chiefly the rectum or sigmoid flexure, or the 
pelvic peritoneum. The changes taking place on the surface of the 
ovary and in the pelvic peritoneum seem at first to consist of the forma- 
tion of a fine plastic membrane from which adhesions subsequently 
develop. As the result of adhesions and a thickening of the capsule 
of the ovary,' retention cysts, usually folUcular in nature, although 
sometimes of lutein origin, ensue. Not infrequently the ovary is 
found to be embedded in a mass of adhesions, but is not otherwise 
involved. The method of ovarian infection and its character in cases 
of gonorrhea are of the utmost importance, because of their bearing on 
conservation of the ovary when operating upon cases of pelvic inflam- 
matory disease. The recognition of the fact that in the vast majority 
of cases the infection is due to surface contamination, and is not the 
result of gonococci within the ovary, is of the utmost importance. 
The prognosis in cases of conservation would naturally be much less 
favorable if the latter were the case. In some cases the disease may 
subside without further involvement. In pelvic inflanmiatory disease 
peri-oophoritis is the most frequent pathologic condition encountered. 
Among 490 ovaries removed for pelvic inflammatory disease in the 
Gynecologic Department of the University of Pennsylvania, 266 were 
the seat of a peri-oophoritis, 122 of an oophoritis, in 44 abscesses were 
present, 17 were cases of tubo-ovarian cysts, and 41 were tubo-ovarian j 
abscesses, showing that peri-oophoritis is more than twice as frequent ^ 
as any other inflammatory lesion. In considering the frequency from 









>-o5 4:=?^- -^"^5^ "© 


Flo. 22. — Cross-section Thhoihh ax Ovaiiian Ausrcss of Lutein Oukiin. 
Thr prcHfnoc of acute oophorilia ia apparnnt. nml in charactprizcd by infiltration of polymorphonuclrnr 
koryiM. wrntii. fni- blood, and a few plasma ccIIb. The lutoin lining of tlu> abiiccsii can still be (lislinniiishcd. 
1 in thi' l.iltiT l.iiiitifin that the inflammatory reaction is most intense ( X l.i). 

Fig. 23. — Pyosalpinx and Ovarian Ab 
The tube has been coiiverted into a club-shaped pyosalpinx. On section, the walls were found to be thick- 
ened and edematous. The ovary was enlarged, covered with adhesions, and was found to be the seat of an 
abscess, evidently the result of an infection of a corpus luteum. No communication existed between the ab- 
scess ca\'ities of the tube and ovary. 

Fig. 24.— Tubo-ovarian Cyst. 

Tb« tube has been converted into a retort-shaped, thin-walled cyst, the 

large serous accumulation of the ova 

I of which communicates with a 


a study of the statistics just cited, it should be taken into consideration 
that this is a conservative clinic, and that many ovaries the seat of a 
peri-oophoritis have not been removed, whereas those organs the seat 
of a more severe lesion, such as advanced oophoritis or an abscess, 
have been excised almost routinely. 

Oophoritis. — In many instances a peri-oophoritis may extend to the 
substance of the ovary. It has been suggested by some authors that 
in rare cases the gonococcus may reach the ovary by way of the blood- 
or lymph-channels from either an infected uterus or a diseased tube. 
Theoretically this is, of course, possible, but its occurrence has, how- 
ever, never been proved and is open to grave doubt. The author has 
never seen a case of gonorrheal peri-oophoritis or oophoritis without an 
accompanying endosalpingitis. The most frequent route of infection 
is through a recently ruptured folhcle. As a result of infection the 
ovary becomes enlarged and edematous, and the tendency for the 
formation of retention cysts becomes increased. Such ovaries are 
rarely larger than a hen's egg, and are often but Uttle increased in size. 
During the chronic stage sclerotic changes are common, and the ovary 
may even be smaller than normal. As a rule, multiple retention cysts 
are present. Occasionally one or two of these show a tendency to 
become pedunculated, or the cysts may be deep in the ovarian stroma. 
The periphery of the organ is chiefly involved, and presents a more or 
less well-marked inflammatory reaction of either an acute or a chronic 
character. Some specimens may show a marked excess of fibrous 
tissue, whereas in others the tendency toward fibrocystic degeneration 
may be observed. Very often the number of normally developed 
follicles is much reduced. 

Abscess of the Ovary. — This usually results from infection of a 
follicle or a corpus lutoum. The follicle ruptures in an ovary per- 
haps previously the seat of a peri-oophoritis, and in this way gono- 
cocci gain access to the substance of the organ. As has been 
previously stated, this may result in a simple oophoritis or an abscess 
may occur. I-]ither a Graafian follicle or a corpus luteum may, there- 
fore, become the seat of suppuration. Mixed infections are not in- 
frequent. Jadassohn' believes that these lesions are pseudo-abscesses. 
Sometimes the tissue surrounding a Graafian follicle or a corpus luteum 
becomes involved, and a true interstitial abscess results. A general 
oophoritis accompanies all ovarian abscesses. Interstitial abscesses 
may, perhaps, occasionally occur independently of the rupture of a 
follicle. Ovarian abscesses vary from those of microscopic dimen- 
sions to those the size of the fetal head or even larger. The ovary can 

' Jiulassohn; Verhandl. dea IV. Dculsclicn Dcrinat. Kong., Vienna. 


accommodate itself more readily to enlargement than can the 

Tubo-ovarian Cyst. — This is a combination of a hydrosalpinx and 
a retention cyst of the ovary, the lumen of the one communicating 
with the cystic cavity of the other. This lesion is produced by the 
fimbriae becoming adherent to the surface of the ovary, and the subse- 
quent rupture of a follicle at the point of adhesion. The tube usually 
resembles an ordinary hydrosalpinx, except that the distal extremity is 
adherent to or buried in the ovary. The ovarian portion of the cyst 
is generally about the size of a lemon, but it may be much larger. 
The cysts occasionally show a tendency to become pedunculated, and 
are generally moderately thin walled. The inner surface is smooth, 
and the contents are similar to those of a hydrosalpinx. The com- 
munication between the tube and ovary is usually a free one. 

Tubo-ovarian Abscess. — The etiology of a tubo-ovarian abscess is 
similar to that of a tubo-ovarian cyst. Less frequently an ovarian 
abscess may rupture directly into the body of an adherent tube, and 
in this way a communication between the two be established. Tubo- 
ovarian abscesses are generally somewhat smaller than tubo-ovarian 
cysts, and are likely to be more adherent. Occasionally an ovary the 
seat of a tubo-ovarian abscess may also contain other areas of suppura- 
tion, and retehtion cysts are often present. In shape and appearance 
the tube resembles an ordinary pyosalpinx. The pus in these speci- 
mens is thick, creamy, greenish, yellowish, or blood-streaked, and dur- 
ing the acute stage it contains numerous gonococci. During the 
chronic stage gonococci are less abundant, and not infrequently they 
are absent or of attenuated virulence. Cultures or smear preparations 
should be made from cureted particles of the abscess-wall, rather than 
from the free pus, as the former locaUty is more likely to contain active 
organisms. The mesosalpinx is, as a rule, much thickened. 


£ r ? 

Fig. 20.— Ti'BO-ovARiAN Abscess. 
The tube presents the usual appearance of a pyosalpinx. except that the distal extremity is buried in the 
underlying ovary and the lumen of the tube communicates by a wide opening with an ovarian abscess that con- 
stitutes the greater bulk of the latter organ. The contents of the abscess consist of moderately thin, purulent 


Gonorrhea in the adult is usually contracted tkrough sexual inter- 
course. Although much has been written of other modes of infection, 
the fact remains — and but few gynecologists or genito-urinary special- 
ists of wide experience will refute the statement — that of every hundred 
gonorrheics, ninety-nine contracted their infection through coitus. 
It must be remembered, however, that gonorrhea may be contracted 
by other means, and for this reason patients should be given the 
benefit of the doubt. One reason why gonorrhea is not often con- 
tracted except through sexual congress is due, as has previously been 
pointed out, to the fact that if exposed to room temperature or allowed 
to dry, the gonococcus loses its virulence or perishes in a few hours. 
Were it not for these characteristics, gonorrhea would be much more 
prevalent, and epidemics would occur frequently. With few ex- 
ceptions the gonococcus develops only on columnar epithelium, and, 
therefore, in order to transmit infection, it is necessary for the secretion 
containing the gonococci to be introduced upon such soil in a com- 
paratively short time after its discharge from its original host. From 
this it will be ajjparcnt that gonorrhea may, in rare instances, be ac- 
quired without sexual intercourse, and authentic cases are on record in 
which the disease has been transmitted through the medium of in- 
fected towels, clothing, surgical dressings, douche-nozles, wat(>r-clos('ts. 
or even the bath-tub or the swimming-pool. Although rare among 
adults, hand infection has been observed. Men have been infected as 
the result of using second-hand condoms, which they obtained from 
their female partners or from the keepers of houses of prostitution, 
these unfortunates falling victims to the very prophylaxis they were 
attempting to carry out. Instances are not lacking to show that pa- 
tients have at times been contaminated through dirty instrumenta- 
tion, or as a result of improper aseptic technic during pelvic examina- 
tions, local treatment, (jr minor surgical operations. Among children, 
and in organs other than the genitalia, gonorrheal infection usually 
takes place by different means than those mentioned. These modes of 
infection will l)e dealt with under their respective headings. 

When infection takes ])lace, the number of grjuococci that ol)tain 
access to the urethra or other portions of the genital tract is extremely 



small. Wertheim's' experiments tend to show that the actual number 
of gonococci introduced upon the mucous membrane is of comparative 
unimportance. Abrasion of the surface upon which the organisms are 
deposited is not necessary for infection. The period during which the 
organisms are multiplying, and before subjective symptoms result, is 
known as the stage of incubation. Accurate statistics relative to the 
period required for the incubation of gonorrhea in women are obtained 
with difficulty, as the initial symptoms of this disease in the female sex 
are often so slight, and of so insidious or transitory a character, that 
the actual date of onset is difficult to determine definitely, and, as a 
further hindrance, the onset is, as a rule, so mild that the physician is 
rarely consulted until the disease has made considerable progress. 
In fact, when the infection is confined to areas below the internal os, 
it is not uncommon for the patients to be in ignorance of the existence 
of the disease. In the male the condition is different, and it is com- 
paratively easy to obtain accurate data on this point. The following 
statistics are gathered from the report of 470 cases by Eisenmann, 
Hacker, and Hoelder: 

Period of incubation 1 day 

1 day in 

11 cases 

2 days ' 


3 . " " 


4 " " 


5 " " 


6 " " 


7 •' " 


8 " " 


9 " " 


10 " " 


11 " " 


12 " " 


13 " " 


14 " ' 


19 " ' 


20 " ' 



30 " '• 



470 cases 

The statistics by Lanz- compiled from 40 carefully selected cases 

Period of incubation 1 day in 2 cases 

" 3 days " 15 " 

" " " 4-7 " " 17 " 

;; ;; " 8-14 " " 3 " 

" 20 days or more " 3 " 

40 cases 

Keyes' records that the average incubation in 34 primary attacks 
of urethritis was six days, and that among patients who had previously 

' Wertheim: Wien. klin. Woch., 1894, No. 24. 

• Lanz, A.: Arch. f. Dermat. u. Syph., Vienna and Leipzig, 1893. 

' Keyes, E. L.: Diseases of the Genito-urinary Organs, 1911, p. 159. 


had gonorrhea, the average duration among 76 cases was 4.88 days. 
Of the primarj- attacks, 20 per cent, appeared prior to the fifth day, 
and of the secondary attacks, 55 per cent, became inanifest in a like 

From these studies it will be seen that the greatest number of cases 
develop on the third day, and that more than two-thirds become evi- 
dent within the first week. An incubation period of more than ten 
days is extremely rare, and the more carefully these cases are observed, 
the fewer will be found to exceed this period. Although undoubtedly 
authentic cases have been reported in which the disease became mani- 
fest more than two weeks after infection, — and, indeed, Lanz quotes one 
case in which the incubation period w^as seventy daj-s, — such reports 
should be regarded with suspicion, for even if the patient's veracity is 
beyond dispute and a previous infection can be excluded, the possi- 
bility of accidental inoculation must always be borne in mind. Ex- 
tremely short periods of incubation, such as twenty-four hours or less, 
are also open to strong doubt, and are suggestive of a previous infection. 
In these patients the condition is "generally due to the lighting up of 
an old chronic condition that had previously been overlooked. The 
period of incubation is of importance, at least theoretically, as it draws 
a sharp line of distinction between gonorrhea and the traumatic or 
chemic inflammations, the reactions of which occur within a few hours 
after the injection of the etiologic factor. Experimental inoculations 
with pure cultures of gonococci have produced a urethritis in periods 
varying from twelve to seventy-two hours. These variations in time 
are due to a number of factors. Indubitably great differences exist in 
the resistance power of various individuals to infection bj' the gonococ- 
cus. That different strains of gonococci have varj'ing degrees of viru- 
lence has also been pointed out by many authorities. Dandier' sug- 
gests that the microorganisms present in acute gonorrhea produce an 
acute inflammation, and that the gonococci from a clironic case, when 
infecting another individual, produce a chronic condition. Doderlein 
makes a somewhat similar statement. That some gonorrheas are sub- 
acute from the onset is true, but ample proof can be adduced that 
this theory does not hold good in all cases. As has previously 
been stated, however, the virulence of the gonococcus is somewhat 
variable. That different degrees of virulence exist among gonococci 
is indicated by the fact that several individuals contaminated at the 
same .source have all been observed to develop metastatic gonorrhea. 
Ahmann's^ experiment is still more suggestive. This investigator 

' Handler: Jour. Amer. Med. Assoc, February 1, 1908, p. .339. 
' Ahmann: Arch. f. Derniat. u. Syph., 1897, vol. xxxix, p. 323. 


inoculated the health}^ urethra of a man with blood from an individual 
suffering from a gonorrheal septicemia: not only did a urethritis 
result, but also a general gonorrheal infection, with localization in the 
lung and synovial sheaths. Trauma to the urethra is a predisposing 
factor to gonorrhea. McDonagh' states that the shorter the period of 
incubation, the more acute is the case likely to be. The same authority 
believes that subsequent attacks are prone to be of longer duration, 
and of a more chronic character, than are first infections. First at- 
tacks are usually more severe and acute, so far as local manifestations 
are concerned. Subsequent attacks are more prone to be complicated 
by arthritis, endocarditis, or other local or general evidences of a 
gonosepticemia. Morton- believes that gonorrhea in tuberculous or 
debiUtated patients is prone to be subacute from the onset and to run a 
protracted course. The part attacked is also a factor to be taken into 
consideration in studying the duration of the period of incubation, 
some locations causing symptoms and being more favorable for the 
development of the gonococcus than others. Bunuii rightly lays 
particular stress upon this point. 

The gonococcus is, indeed, a pecuhar organism; it is grown only 
with extreme difficulty on artificial media, perishing rapidly if not fre- 
quently transplanted, and under such conditions easily destroyed by 
extraneous influences, such as heat, cold, or weak antiseptic solutions ; on 
favorable soil, however, like the female genital tract, it produces a dis- 
ease the chronicity of which is one of its chief characteristics. The 
dictum of Noeggerath, "Once infected always infected," is borne out in 
a large proportion of cases, and is true of nearly all female patients that 
' are not subjected to proper treatment. Indeed, the chronicity of the 
disease has led to the well-known aphorism that ' ' All attacks of gon- 
orrhea are curable except the first." Compared with other pyogenic 
microorganisms like the streptococcus or the staphylococcus, the gono- 
coccus possesses little or no power of penetration, and although the 
mucous membranes are not its only habitat, nevertheless it is on these 
structures that it usually develops. 

In the genital tract of both men and women, but more especially in 
the latter, the gonococcus may lie dormant for indefinite periods. In 
women the three areas most frequently infected are the urethra, the 
cervix, and Bartholin's glands. In a given case the part infected de- 
pends upon certain conditions. Thus if the introitus is small or the 
male organ disproportionately large, the urethra is most likely to be 
contaminated, whereas if the pelvic floor is relaxed and the external 

' McDonagh, J. E.: The Practitioner, 1909, vol. boodi, p. 534. 

' Morton, H. N.: Genito-urinary Dineases and Syphilis, Philadelphia, 1912, p. .39. 


orifice gaping, the cervix is most frequentlj- infected. In women or 
young girls infected during an incomplete coitus, or as a result of rape, 
the urethra and external genitalia are naturally most exposed to con- 
tamination. A urethritis may often be warded off by washing out the 
urethra by urination immediate^ after an impure coitus, or infective 
material may be removed from the cervix by a copious antiseptic 
douche taken immediately after a suspicious intercourse. These fac- 
tors doubtless play a decided part in the infection of one area and the 
escape of another. In the urethra, because of the anatomic formation 
and the short length of the canal, the subjective symptoms are usually 
mild, consisting of, at most, a slight frequency of and burning on mic- 
turition, which rarelj" last more than a few days. The chief symptom 
of a cervicitis is an increase, usually not great, of leukorrheal discharge, 
which usually also changes somewhat in character, whereas a bartho- 
linitis often results in nothing more than a slight itching or irritation of 
the vulva. Even with acute infection of all these locations the symp- 
toms are sometimes so transient or of so mild a character that the 
patients, unless on the lookout for'infection, pay no heed to their con- 
dition, and when the disease becomes chronic, they are, of course, 
ignorant of its existence. This is especially likely to be true if the 
patient is a woman of unclean habits or of sluggish sensibilities. Even 
when actual sj'mptoms are noticed, a feeling of shame will sometimes 
prevent the patient from consulting a physician, and as the acute stage 
disappears quickly, the woman naturally believes that nothing serious 
has occurred and the entire incident is often forgotten. Menge^ states 
that the manner in which the disease is often spread is as follows: A 
husband infected with a chronic gonorrhea, out of courtesy to his young 
wife, and because he does not wish to cause her pain, does not rupture 
the hymen at the first intercourse; hence the infectious semen is de- 
posited at the orifice of the urethra and at the openings of Bartholin's 
glands. As a result, an acute vestibular gonorrhea, urethritis, and 
bartholinitis occur. This condition, of course, causes considerable 
pain, and intercourse ceases. If the woman is seen in this condition !)>■ 
a competent physician, she can easily be tieated and the spread of the 
disease prevented; but most of these patients, on account of a sense 
of modesty, do not consult a physician, and attribute these symp- 
toms to defloration. As a rule, they employ douches, and in this way 
carry the infected material from the outside into the vagina, and thus 
transfer the disease to the cervix. It does not seen> to the author that 
this mode of infection is a very frequent one. The incubation stage of 
gonorrhea lasts at least two or three days, and it does not appear likely 
' .Mongc, K.: Hiiiiflbucli <1. GeschlechLskrankhciten, Vicmiii, lillO. 


that, on the average honeymoon, the hymen would remain unruptured 
for the period required for the development of subjective symptoms. 

The chronicity of gonorrhea attacking areas below the internal os 
accounts for many of the peculiarities of the disease, and, prior to the 
discovery of the gonococcus, proved a stumbling-block to the medical 
man, causing the greatest confusion regarding the etiology of the 
condition. It can be readily understood how it is possible for a 
woman innocently to infect a man. This, however, does apply to the 
average prostitute, who is always on her guard for symptoms and is 
usually aware of her condition. It also explains the frequent cases 
of infection from api^arently healthy individuals. No trustworthy 
evidence has ever been adduced to show that actual immunity to gon- 
orrhea exists in the human species. The frequent cases cited, in which 
two or more men have had intercourse with an infected woman on the 
same night, and only one or perhaps two have contracted gonorrhea, 
must be explained on other grounds. It is quite possible that in some 
of these instances a douche following the first intercourse has saved all 
but the first man; personal hygiene, such as washing or urination 
immediately following, may often prevent infection. It is a well- 
established fact that a female gonorrheic may transmit infection at 
one time and not at another. Doderlein' states that men in whom the 
external urinary meatus is large are more likely to contract gonorrhea 
than are those possessing a small, contracted orifice. The general 
health of the person exposed, together with the individual suscepti- 
bility of the individual, may also play a small part in the question of 
infection. Lenehan- has reported a remarkable case in the man in 
whom a congenital double urethra was present. The upper and smaller 
urethra was free from infection, but in the lower a well-marked gon- 
orrheal urethritis was observed. 

Coitus with an infected woman soon after her menstrual period is 
extremely likely to produce infection, whereas the healthy woman is 
herself especially inceptive to gonorrhea at this time. Indeed, the 
infectiousness of gonorrhea at the menstrual period had led to the com- 
monly accepted belief, among a certain class of the laity, that the 
disease may be contracted from a healthy woman by coitus at this 
time. This peculiarity of the disease may be explained by the con- 
gestion of the genital organs which is always present at menstruation, 
and which results in the Uberation, from the tissues, of more abundant 
flora of gonococci. The diminished acidity of the vaginal secretion 
which follow the flow not only favors the multiplication of gonococci 

' Doderlein: Quoted by Kustner: Lehrbuch der Gynakologie, 1904, p. 389. 
2 Lenehan, W.: Amer. Jour. Urol., November, 1912, p. 59S. 



which are already present, but partially accounts for the peculiar in- 
ceptiveness which uninfected women exhibit toward gonorrhea at the 
menstrual period. 

Chronic or, as Luther^ prefers to designate it, latent gonorrhea, is 
most likely to evince exacerbations after excesses of anj'^ kind or 
exhausting physical exercise; as a consequence, during the periods 
following such indiscretions, intercourse with infected individuals is 
peculiarly hkely to be followed by infection. Latent gonorrhea is 
characterized by the fact that many gonococci are estabhshed beneath 
the surface of the mucosa, but are seldom observed on the surface or 
in the discharge. A woman with latent gonorrhea may perhaps co- 
habit with a man for long periods without transmitting the disease. 
The fact must never be lost sight of that for infection to take place 
the gonococcus must be brought in contact with the mucous mem- 
brane, and that anything which tends to lessen the likelihood of this 
occurrence decreases the probabihty of contracting gonorrhea. In the 
so-called latent cases of gonorrhea the gonococcus appears at times 
partially to lose its virulence, or the hosts become slightly immune to 
their own particular organism. This is probably more apparent than 
real. Nevertheless, such individuals may infect others, or, in some 
cases, themselves cohabit with infected persons without developing 
symptoms of an acute attack. These constitute the class of persons, 
occasionally met with, who seem to be immune to gonorrhea. In 
chronic gonorrhea the secretions may for a time contain few or no 
gonococci. This fact is amply borne out by clinical and bacteriologic 
evidence. A curious feature of gonorrhea is shown by the fact that a 
husband may infect his wife, and practise abstinence during the course 
of the treatment of his disease may, upon resuming marital relations 
be inoculated by her and develop an attack pcrhajis more severe than 
his original one, or husband and wife may both suddenly manifest 
severe symptoms. A lack of knowledge of this peculiarity of the 
microorganism has frequently led to accusations of infidelity. A 
curious example of this queer feature of the disease, and one instanc- 
ing the peculiar latency and chronicity of gonorrhea, came under the 
author's notice a few years ago: Six weeks after marriage the hus- 
band, who was ten years older than his wife, was forced to leave home 
on an extended trip; upon his return his wife informed him (hat she 
had developed a purulent leukorrhea a few days after his departure. 
The family physician was consulted, and he pronouncetl the wife's 
condition to be gonorrhea, the tyi)ical organisms being found in smear 
prejiarations. On this evidence the husband instituted divorce pro- 
' Luther: Monats. f. (_!eb. u. Ciyiiiik., vol. xvii, \o. I, p. 71. 


ceedings, based on infidelity. Fortunately, at this period the wife 
visited a gynecologist, who induced the husband to stay the legal pro- 
ceedings until after he had been examined by a genito-urinarj^ special- 
ist. Up to this time the husband had denied infection, and, indeed, 
no subjective or objective symptoms of a chronic gonorrhea could be 
elicited by any of the ordinary means. Repeated cultures and smears 
from the urethra were negative, and it was not until deep massage of 
the prostate had been resorted to that gonococci could be demon- 
strated. It was only then, when confronted with this incontrovertible 
evidence of his infection, that the husband could be convinced of his 
condition. He admitted later that, twenty years previously, when 
quite a young man, he had suffered from a slight urethral discharge 
that had appeared after an illicit coitus — the only time in his life, so 
he stated, that he had had intercourse with a woman other than his 
wife. In this case both husband and wife were persons of a high degree 
of veracity and integrity, and there is every reason to believe that their 
statements were true. 

Regarding the persistence of the gonococcus in the prostate, opin- 
ions differ. Cohn,^ Wossidle,- and Goldberg' believe that the organism 
is rarely found in this location after two years. On the other hand, 
Finger,* Neisser,^ and Putzler express a contrary opinion. Sax^ re- 
ports a case in which gonococci persisted in the prostate for fourteen 
years. MacMunn" relates a somewhat similar case in which a man 
infected his wife fifteen years after contracting gonorrhea; Valentine* 
reports a still more remarkable case, in which a man infected his wife 
thirty years after his apparent cure, and after having fulfilled his 
marital relations with her for twenty-four years. Apetz^ reviews a 
case of gonorrhea after six years without fresh infection, but with a 
concomitant outbreak of polyarthritis and metastatic conjunctivitis 
and other eye complications. Such instances are, however, extremely 
unusual. Gonorrhea in the female may persist indefinitely, but in the 
male a course of more than three or four years is extremely rare and 
should be viewed with suspicion; in the majority of cases a reinfection 
is more than likely to have occurred, von Notthaft"* states that it is 
unusual for gonorrhea to persist in the genital tract in the male for 

' Cohn: Cent. f. Krankh. d. Ham- u. Se.-tualorgane, 1898, p. 229. 

' Wossidle: Die Gonorrhoe des Mannes u. ihre Komplikationen, Berlin, 1903, p. 206. 

' Goldberg: Cent. f. Krankh. d. Harn- u. Sexualorgane, 1906, vol. xvii, No. 5. 

* Finger: Die Blennorrhoe der Sexualorgane, 1905. 
'Neisser: Verhandl. d. Deut. Dermat. Gesellsch., Vienna, 1894. 

* Sax: Trans. Amer. Urol. Assoc, 1909, Brookline, 1910, vol. iii. 
' MacMunn, J.: Lancet, November 24, 1906, p. 144.5. 

* Valentine, F. C: Phila. Med. Jour., July 8, 1899. 
5 Apetz, W.: Miinch. med. Woch., vol. 1, p. 1340. 

1° V. Notthaft: Arch. f. Dermat. u. Syph., 1904, vol. Ixx, p. 277. 


more than three years, and Keyes^ writes that he has never known the 
gonococcus to survive in a male host for more than a similar period, 
and that in at least 90 per cent, of cases they disappear with or with- 
out treatment within a year. On the other hand. Pollock and Harri- 
son- believe that in a large proportion of cases recovery is not complete. 

Husband and wife may cohabit regularly and may both ho infected, 
and yet manifest no subjective symptoms of the disease, whereas a third 
individual having intercourse with either one may develop an acute 
attack, or the gonococci of a married pair may be transferred to a 
third person, and from them to one of the couple, setting up a severe 
lesion in its original host. These instances are sufficient to show that 
gonococci maj' remain latent for prolonged periods, but that when trans- 
ferred to another individual, are capable of setting up severe inflamma- 
tion, and may be transferred either through the second or by a third 
person to the original host, and in the latter produce an acute attack. 

Jadassohn^ has suggested that some chronic gonorrheas may be 
rendered acute by superinfection with their own gonococci. Gono- 
cocci may lie dormant in the genital tract of women for j^ears, becom- 
ing active with the advent of pregnancy, miscarriage, or abortion, 
and then produce sepsis. Women are usually infected by men suf- 
fering from chronic uretliritis. An old gleety discharge ("morning 
drop") is one of the most prolific causes of infection. Men so afflicted 
frequently consider themselves cured, or may actuallj^ be told so by 
some hard-worked physician, who has neither the time nor the knowl- 
edge and facilities required to make a thorough examination. On the 
other hand, a chronic urethritis maybe present in the man and produce 
absolutely no symptoms until a slight excess of alcohol may give rise 
to a mild exacerbation, at which time the urethral discharge may con- 
tain virulent gonococci. The prevalence of gleet is well known, and 
largely accounts for the frequency of gonorrhea among married women. 

Racial Susceptibility.— It is difficult to determine if any racial sus- 
ceptibility to gonori'hea exists. It is connnonly asserted that the 
African race is peculiarly susceptible to gtmorrhea. It ap])ears to be 
a fact that gonorrhea is relatively more frequent among negroes than 
among whites. What proportion of this can be laid at the door of 
immorality and uncleanliness is impossible accurately to estimate, 
but this is probably the chief factor. Research has failed to sliow 
that gonorrhea is more malignant in new peoples than in those in- 
accustomed to the disease for generations, and it seems likely tiuit the 
fection is quite as severe at the present date as it was g(>n(Tations ago. 

' Koyes: Amer. Jour. Med. Sei., Jiinuary, lOl'i. 

'Pollock, C. E., ami Harrison, L. \V.: (!onocoeciil Infi'clion, I.oimIoii, HHJ, p. HI 

' Jadas.sohn: C'lirn'sp.iinlciiz-BI. f. .schw. .Verzli-, M;iy 1, lx'."><. 



The general and wide-spread evil effects of gonorrhea can hardly 
be overestimated. There is probably no other disease known to naedi- 
cal science that has caused as much suffering and sorrow throughout 
the civilized world as has gonorrhea. Neisser states that, with the 
exception of measles, gonorrhea is the most wide-spread of all diseases. 
It is the most potent factor in the production of involuntary "race 
suicide," and, by sterilization and abortion, does more to depopulate 

O'Yo lO 


30 AO 



\jx\der 1 




£.y rs 



















50- -sp 


60- 6c) 









Fig. 27. — Age Distribution of Death from Venereal Disease, Per Cent. (Brown, H. A.: New York 
Med. Jour., June 17, 1911, p. 1185). 

the country than does any other one cause. The number of deaths 
annually that can be traced directly to this disease is difficult to esti- 
mate, but it is undoubtedly large. The majority of deaths due di- 
rectly to this disease are usually tabulated under other headings in 
mortality statistics. An example of this in the recent Mortality 
Statistics^ issued from Washington in which, from 1900 to 1909, the 
average death-rate due to gonorrhea (excluding stillbirth) for both 

' Mortality Statistics, 1909, Department of Commerce and Labor, Bureau of Census, 
Washington, 1912, p. 86. 



infants and adults is placed at 31 and 32 per 100,000 respectively. 
These statistics are misleading, as they refer only to the cause of death, 
as stated in the death certificate, and naturally do not include the 
vast number of deaths that are directly due to gonorrhea, and that 
are usually recorded in the death certificate as pelvic abscess, peri- 
tonitis, septicemia, etc. 

Of the 500,000 prostitutes who constitute a part of the population 
of our great cities, it is estimated that 40,000 die annually. Of these 
deaths, 30 per cent, are due to gonorrhea. Among the deaths follow- 
ing abdominal operations a very definite percentage can be traced to 
this type of infection. Price asserted that 90 per cent, of all pelvic 
infections are of gonorrheal origin. Norris, whose statistics were 
compiled from dispensary patients, places the proportion at 80 per 
cent.; Pozzi and Frederic, at 75 per cent.; Clark, at 50 per cent.; 
Daxis and Noble, at from 5 to 10 per cent. ; and Robb,^ at 25 per cent. 
Grandin states that 60 per cent, of all gynecologic operations are per- 
formed for gonorrhea or its results. Kaan- states that in Boston from 
5 per cent, to 16 per cent, of all gynecologic operations are performed 
for gonorrhea. This author believes that many writers place too much 
stress upon the gonococcus as an etiologic factor in pelvic inflammatory 
diseases. Kaan's report is, however, based upon clinical findings 
only, no bacteriologic studies having been performed upon the cases 
reported bj' him. Morrow and Bridgman^ report th^t in the State 
Training School for Girls at Geneva, Illinois, approximate!}' 55 per 
cent, of the inmates have gonorrhea at the time of their entrance. 
The average number of commitments a year to this school is about 

Statistics computed from the reports of Briise, Sanger,'' and Eber- 
hard show that in a series of 1361 gynecologic patients, 12.77 per cent, 
were infected with gonorrhea. From these figures, therefore, placed 
at a conservative estmatc, gonorrhea may be said to cause at least 
50 per cent, of all pelvic inflammatory diseases. 

The percentage of sterility traceable to gonorrhea is more difficult 
to estimate. Neisser, ]5unun, and Furl)riiiger state that 30 per cent, 
to 50 per cent, of all childless marriages are directly caused by gon- 
orrhea. In France statistics have been accurately comi)ilcd, and it 
has been found that, of about 10,000,000 families, 2,000,000 are with- 
out issue. These results, according to Neisser, would tend to show 

' Robb: Trans. Amer. Gyn. Soc, 1906. 

' Kaan, G. W.: Boston Med. and Surg. Jour., April 11, 1912, p. 559. 

• Morrow, L., and Bridgnian, O.: Jour. Amor. Med. Assoc, May 25, 1912, p. I")!)}. 

* Sanger, W. W. : History of Prostitution, 1906. 


that gonorrhea is the etiologic factor in nearly 1,000,000 sterile mar- 
riages in France alone, and this does not include the vast number of 
" one-child sterilities" due to this condition. Other authorities place the 
proportion of sterility resulting from gonorrhea at figures varying from 
30 per cent, to 50 per cent. Funck-Brentano and Plauchu,^ in a series 
of 134 sterile women, found that in 37 the condition was due to gon- 
orrhea. Lobenstine and Harrar- found that the average birth-weight 
of the infants of gonorrheal mothers was lower than of babies of 
mothers unaffected with this disease. Their conclusions were based 
on the observation of 150 babies of normal mothers, as compared with 
50 babies of afebrile gonorrheal mothers, and 50 babies of gonorrheal 
mothers with fever. The birth-weight of these infants was lower, the 
initial loss of weight greater, and the subsequent gain slower, than in 
babies of non-gonorrheal mothers. These authors consider that, in 
the late months of pregnancy, gonorrhea is a frequent cause of pre- 
mature births. Many authors claim that placenta prsevia and ad- 
herent placenta are often caused by a preexisting gonorrheal endome- 
tritis, but this has not yet been definitely proved. Placed at a low 
estimate, gonorrhea may be said to cause 20 per cent, of all the blind- 
ness in the world. In the United States census for the blind and deaf 
for 1900 it was shown that ophthalmia neonatorum was the cause of 
25.02 per cent, of all the blindness. It has been computed that, in 
Prussia, venereal diseases cause an annual loss to the State of 90,000,- 
000 marks ($21,600,000). The Royal Commission on the Blind, the 
Deaf, and the Dumb, which reported in 1889, estimated that 7000 
persons in the United Kingdom had lost their sight as a result of 
ophthalmia. They state further that the number of people disabled 
as a result of this condition represents an annual burden to the com- 
monwealth of £350,000. There is every reason to believe that gon- 
orrhea and other venereal diseases are quite as prevalent in this coun- 
try as in Europe. 

Frequency. — On account of the secret nature of the malady, the 
frequency of gonorrhea in civil life is difficult to estimate accurately, 
and more especially is this the case with gonorrhea in the female. 
In 1901 the Committee of Seven^ on Prophylaxis of Venereal Diseases 
in New York sent out a circular letter to 4750 physicians in New York 
City asking for data regarding venereal disease. A large number of 
the hospital and dispensary reports from the same city were also 
examined. It was estimated by this Committee that at that time 

' Funck-Brentano, L., and Plauchu, E.: La Gynecologie, October, 1912, p. 577. 
' Lobenstine and Harrar: Bull. Lying-in Hosp., New York, December, 1906. 
' "Report of the Committee of Seven," Med. News, December 21, 1909. 


there were 220,000 venereal patients walking the streets of New York. 
Holton' places this number at 200,000. A special committee of the 
New York ^Medical Association recently placed the number of venereal 
patients in New York at the same figure. The large proportion of 
patients upon whom the statistics for this report were based were 
males. Reports of 23,196 cases of venereal disease were made by 678 
phj'sicians. It is a significant fact that 40 per cent, of all the female 
gonorrheics suffered from pelvic symptoms. 

Gonorrhea attacking the area below the internal os frequentlj' pro- 
duces only mild symptoms, which are often overlooked by the patient 
herself, and, as a result, a definite proportion of such women do not 
go to phj'sicians for treatment. In addition chronic gonorrhea in 
these localities is not infrequently overlooked by the average physician. 
It is, therefore, safe to state that many female gonorrheics were over- 

In 36 dispensaries and charitable institutions 14,649 cases of gon- 
orrhea and 7607 cases of syphilis, a total of 22,256 cases, were treated 
during the year. In addition, there were 9452 cases grouped as ven- 
ereal in which, presumably, a positive diagnosis had not been made, 
bringing the total to 31,708. This does not include 3907 cases of 
chancroid, 898 cases of epididymitis, 332 cases of cystitis, 414 cases of 
bubo, 261 cases of venereal warts, 172 cases of balanitis or phimosis, 
523 cases of ophthalmia, 142 cases of ophthalmia neonatorum, 19 cases 
of vulvovaginitis in children, and 195 cases of hereditary sj^philis. 
Many cases of venereal disease are treated under other names, since 
some hospitals have rules forbidding the treatment of such cases. 
Statistics from a number of large institutions were not available to the 
Committee of Seven. This Committee believed that, to obtain a 
true estimate regarding the number of venereal patients in New York, 
their figures should l)e multiplied by seven. Among 4664 women 
treated at the Massachusetts Cieneral Hospital in 1906, 150 had gon- 
orrhea. These figures are, however, undouI)tedIy fallacious, owing 
to the latency and chronicity of gonorrhea in women. It would prob- 
ably be more accurate to say that 150 of these women suffered from 
acute gonorrhea. 

The following statistics, taken from the Committee on Prophylaxis 
of Venereal Diseases, Washington State Medical Association,- state 
that 80 per cent, of all men in large cities have had gonorrhea once or 
several times, 45 per cent, infect their wives, SO jx-r cent, of all opera- 

' Holton; .lour. Amer. Med. Assoc, March 11, 190.5. 

' (Quoted by 11. Guitcras: Urology, D. Appleton and Co., New York and London, 1012, 
vol. ii. 


tions upon women for diseases of the uterus and adnexa are caused by 
gonorrhea, and that 20 per cent, of all bUndness results from the same 
cause. Menge^ states that for every five or six cases of gonorrhea in 
the male there is one in the female. This observer bases his opinion 
upon the fact that gonorrhea, in the majority of cases, is contracted 
through illicit intercourse, and that unmarried men are more licentious 
than unmarried women. On the other hand, it should be remembered 
that in the male the early symptoms of gonorrhea are of such a char- 
acter as to demand early treatment, and, as a result, most cases are 
cured, whereas in women the disease is often so far advanced by the 
time severe subjective symptoms arise that a complete cure is often 
extremely difficult. Furthermore, the chronic stage of the disease, 
when confined to structures below the internal os, is productive of so 
few symptoms that women frequently neglect treatment. In women, 
therefore, the disease averages a longer course than in men. Keyes' 
estimates that 50 per cent, of young men contract gonorrhea. Clark' 
places the proportion at 75 per cent., and Weiss^ at 80 per cent. Neis- 
ser^ states that 75 per cent, of all men and 45 per cent, of all women 
have had gonorrhea, and that 30 per cent, of the females have been 
infected by their husbands. Erb^ found that 48.5 per cent, of all the 
patients who consulted him had suffered from gonorrhea. His statis- 
tics are drawn from 2000 cases. Bettman found that 41 per cent, of 
the patients in a dermatologic chnic had, at some time in their lives, 
contracted gonorrhea. His statistics are based upon 241 cases. 
Yudice, from similar material, found 50 per cent. ; Forchheimer' found 
54.1 per cent, among 258 cases, none of whom were under thirty years 
of age. These included private patients. Cabot* reports that of 
8000 male patients questioned in a large general hospital, over 35 
per cent, gave a history of having had gonorrhea. Sanger^ found 230 
cases (12 per cent.) of gonorrhea among 1930 women examined by him. 
Bierhoff'" estimates that there are in New York today 1,000,000 per- 
sons affected with venereal disease. Of this number, 800,000 are 

' Menge, K.: "Die Gonorrhoe des Weibes," Handbuch der Gesehleclitskranklieiten, 
Vienna, 1910. 

= Keyes, E. L.: Diseases of the Genito-urinary Organs, 1911, p. 97. 

' Clark, J. B.: Essays on Genito-urinary Subjects, New York, 1912, p. 51. 

* Weiss, L. : Med. News, September 10, 1904, p. 487. 

' Neisser: Quoted by Mullowney, J. J.: Tlie China Med. Jour., March, 1912. 

•Erb: Miinch. mod. Woch., 1907, No. 31. 

' Forchheimer, F.: Boston Med. and Surg. Jour., July 30, 1908, p. 101. 

' Cabot: Boston Med. and Surg. Jour., August 3, 1911. 

» Sanger: Die Tripperansteckung beim weiblichen Geschlcchte, 1889. 

'» Bierhoff: New York Med. Jour., November 12, 1910. 


gonorrheics. Gerrish^ places the number of venereal patients in New 
York at 800,000. Sanger^ believed that in 1857 there were 74,000 
venereal patients in New York. The population was at that time 
about 700,000. Morrow' states that venereal diseases contribute a 
sum total of morbidity of nearly double that of all other infectious 
diseases, both acute and chronic. This observer believes that there 
are 250,000 married women in the United States infected with gon- 
orrhea. He computes this estimate on a basis of 8 per cent, of in- 
fection among married women. This proportion may be too liigh, as 
Erb,^ in a recent paper, places this figure at 4.5 per cent. The appar- 
ent discrepanc}^ in these figures may doubtless be partiallj' accounted 
for by the class of patients from wliich. the statistics are compiled. 
Gynecologists see more female gonorrheics, and their methods of ex- 
amination are more thorough than are those of the general practitioner; 
as a result, they are likely to find a greater proportion of infected pa- 
tients than those less skilled in methods of examination. Noeggerath 
estimated 80 per cent. Morrow states that there are 1,500,000 men 
annually infected with gonorrhea" in this country. Seventy per cent, 
of 1155 cases treated, mostly venereal, at Hot Springs, had at the time 
of examination, or had previously had, gonorrhea.^ Hepburn^ re- 
ports that in Baltimore, during 1906, 3090 cases of venereal disease 
were treated by physicians in private practice, and 6390 cases in dis- 
pensaries. During the same year there were treated in Baltimore 575 
cases of measles, 1172 cases of diphtheria, 577 cases of scarlet fever, 
175 cases of chicken-pox, 58 cases of smallpox, and 733 cases of tuber- 
culosis, making a total of 3310 cases of infectious disease, against a 
total of 9450 cases of venereal diseases. 

The frequency of gonorrhea naturally varies in different walks of 
life and under different conditions. Stephenson'' has computed the 
statistics for the following table : 


Number or Cases 

Percentage of 

Puerperal infection 






Married women with fluor albus 

Loose women with fluor albus 


' Gcrrish: Soeial, I'Jll, vol. ii, No. 2. 

» Sanger, W. W.: The History of Prostitution, 1906. 

'.Morrow: Maryland Med. Jour., 1908, p. 260. 

* Erb: Munch, mod. Woch., 1907, No. 31. « The Social Evil in ChiouKo, 1911, p. 298. 

' Hepburn: Yale Med. .Jour., 1908, p. 168. 

' Stephenson, S.: Oplilli.'ilnii:! Xeonaforum, I.onclon, 1907, p. 38. 


Luther^ states that in two large gynecologic dispensaries in Phila- 
delphia 25 per cent, of the patients suffered from venereal disease. 
Bailey^ believes that 75 per cent, of the male and 17 per cent, of the 
female population have at some time had gonorrhea. Schwartz' has 
calculated that 10 per cent, of married men enter wedlock afflicted 
with chronic gonorrhea, and that an additional 10 per cent, acquire 
gonorrhea during married life. Some continental authorities compute 
that 75 per cent, of all male adults and 18 per cent, of all females have 
suffered from gonorrhea. Ivens* found gonorrhea in 24 per cent, of 
his gynecologic patients. Blaschko/ reporting the statistics fi'om Co- 
penhagen from 1876-95, finds that 12.8 per cent, of the population have 
gonorrhea. He also found that, among 600 students in Berlin in 
1891-92, 18.5 per cent, had gonorrhea, and that 20 per cent, of all 
men are infected with this disease once between twenty and thirty 
years of age. According to Emley,* 15 per cent, of all patients in the 
Paris hospitals, 10 per cent, in all the New York hospitals, and 33 
per cent, in all the London hospitals, have suffered from venereal 
disease. Swarts' states that 70 per cent, of all women who come to 
New York hospitals for treatment of venereal diseases are reputable 
married women who have been infected by their husbands; that in 
New York there are annually 12,500 cases of measles, 11,000 cases 
of diphtheria, 'and about 19,000 of tuberculosis — in round numbers, 
41,000 cases of infectious disease. During the same period there are 
243,000 cases of venereal disease. LitchfiekP estimates that in Berlin 
there are annually infected with venereal disease 4 or 5 per cent, of the 
soldiers, 13 to 30 per cent, of waitresses, 16.5 per cent, of salesmen, and 
25 per cent, of students. According to the canvass completed in 
April, 1910, there are in Germany on an average 100,000 persons 
treated daily for venereal disease. Of about 12,000,000 persons in- 
sured in the German Empire, about 750,000 are annually infected with 
some form of venereal disease. From data estimated by the Prussian 
government^ it has been stated that at least 500,000 persons were in- 
fected with a venereal disease yearly. Another, and later, authority" 

' Luther, J. W.: The Pennsylvania Med. Jour., July, 1912, p. 192. 

- Bailey: Boston Med. and Surg. Jour., June 5, 1902. 

^ Schwartz, E., quoted by L. Weiss: Second Annvial Report of the Committee ou 
Prophylaxis of Venereal Diseases of the Amer. Med. Assoc, Jour. Amer. Med. Assoc, June 
30, 1904. 

* Ivens: Brit. Med. Jour., June 19, 1909. 

'Blaschko, A.: Syphilis und Prostitution vom Standpunkte der offentliohen Gesund- 
heitspflege, Berhn, 1893. 

« Emley: Kansas Med. Sec, 1908, p. 428. 

' Swarts: Report of State Sanitary Officers, 1910. 

» Litchfield: Jour. Social Hygiene, December, 1909, p. 174. 

^ Hygienische Rundschau, April, 1902. 

'» Quoted by Kean, J. R.: Military Surgeon, March, 1912, p. 2.51. 


places this figure at 773,000. Of this mass of statistical evidence, 
much of which varies quite widely, the greatest stress should be placed 
on the fig-ures computed by the Committee of Seven on Prophylaxis 
of \'enereal Diseases in New York. The report of this Conunittee 
shows the result of careful work, and an entire absence of any desire 
either to overestimate or underrate the conditions found. 

-\11 statistics taken from civil life are, however, for obvious reasons, 
more or less inaccurate. In the armj^ and navy a different condition 
of affairs exists. Here the men are subject to frequent systematic 
medical examination, hence the statistics derived from these sources 
are undoubtedly more reliable. It has been asserted that venereal 
disease is more prevalent in the army and navy than in civil life. This 
is probably not the case if such reports are compared with statistics 
composed of men of similar age in civilian life. Von Tophy states 
that the relative venereal morljiditj- in armies bears a close relation- 
ship to the prevalence of this class of diseases among the civilians in 
the district in which they are quartered. Munson gives the following 
figures relative to the prevalence of venereal disease per 1000 in armies; 

Germany 29.9 

Russia Hli.O 

Japan 40.0 

Holland • 48.0 

France 49.0 

Au.stria-Hungary 60.0 

Great Britain (home statistics) 173.8 

" " (foreign " ) 522.3 

United States "3.7 

In 1909 the rate of admission for venereal disease in the following 
armies was: 

BrilLsh «7.04 

Austria-Hungary HO. 00 

Frcnc^ 21).0S 

Pru.s.'i.-m 19.0.S 

Bavarian 14.00 

From the foregoing it will i)e seen that venereal diseases are ex- 
tremely prevalent in the United States army. For eighteen years 
preceding the Civil War the morbidity of venereal disease was S7.S0 
per 1000. From 1876 to 1895 inclusive the rate was 82.98, decreasing 
from 107.6 in 1876 to 73.7 in 1895. During this period there was a 
steady decrease in the number of cases of syphilis. In decennial an- 
nual periods from 1868 to 1897 the annual rate of syphilis was 67.20, 
36.45, and 15.63. On the other hand, the rate of gonorrhea, thotigh 
decrea.sing up to 1885, showed a constant increase thereafter, il being 
37.7(i in 1SS5 and 56. 21 in 1S'.)7. In l!H)l, in the entire army (92,4!»1 



men), there were 13,911 cases of venereal disease, equivalent to a 
ratio, on admission, of 150.41 per 1000 — for syphilis, 19.15, and for 
gonorrhea, 93.90. 













■ 13.98 













Venereal Rate 




1899 ' 

13;"). 84 






33 35 



1902 . . 

29 57 


28 11 

1904 . .. : 














Grubbs' presents the following table, showing the prevalence of 
venereal disease in the United States army in various localities, and 
comparing it in frequency with the diseases next most prevalent : 


United States, 
Porto Eico 





Venereal disease . . 











Diarrhea and en- 

' Grubbs: The Military Surgeon, 1909, p. 576. 



The Surgeon General of the Umted States army, in his report for 
the year 1904, states that venereal diseases held first place in admis- 
sions to hospitals, and caused more discharges and rendered more men 
non-efficient than any other single factor. During 1904 venereal dis- 
eases caused 19 per cent, of all admissions to hospital, 15 per cent, of 
all discharges, and 30 per cent, of all non-efficiency because of disease. 
Seven hundred and ten men were constantly on the sick list for venereal 
diseases; a number equal to the loss for the entire year of about 
eleven full companies of infantry. 

STATES NAVY, 1880-1909 

Fiske' states that one man in every seven in the navy develops a 
venereal infection each year. (Table by Kean.-) 

' Fiske: Jour. Amer. Pub. Health Assoc, Mnroli, 1911, j). 181, 
' Kean, J. R.; The Military Surgeon, March, 1912, p. 2.'>1 




United States 

Total Army 









' 1889 . 
' 1890 
» 1891 . 
1 1893 . 
' 1894 . 
1 1895 . 
' 1896 . 
' 1897 . 
1 1898 . 
1 1899 
I 1900 , 





1905 . 









Munson- states that among all troops venereal diseases are al- 
ways more prevalent when on foreign service. He also believes that 
venereal diseases are more severe in tropical climates, and when sexual 
relations are assumed between individuals of different races, the aliens 
suffering more in this respect than the resident population. In this 
connection Kean^ gives the following figures regarding the respective 
races serving side by side in the Philippine Islands for the last quin- 
quennium : 








None in P. I. 






; Establishment of canteen, February 1, 1889. February 21, 1901, Act of Congress 
prohibiting sale of alcoholic drinks in canteen. 

2 Munson: "Camp Diseases," Handbook of Medical Sciences, Wm. Wood and Co., 
vol. n. 

' Kean: The Military Surgeon, March, 1912, p. 251. 



The explanation of this astonishing difference is that the native 
troops are mostly married, a reason that probably applies also to na- 
tive troops of other countries. 

Kerr^ states that of 1,281,472 cases treated in the United States 
Public Health and Marine-Hospital Service between 1886 and 1909, 
263,215, or 20.5 per cent., were of venereal origin. The Surgeon 
General of the United States navy, in a recent report, states that 
venereal diseases constitute the gravest menace to the physical ef- 
ficiency in that service. The five-year period from 1904 to 1908, with 
an average of 43,165 men in the navy and marine corps, shows a total 
number of admissions for venereal and genito-urinarj' disease of 32,852, 
of which number 11,526 were suffering from gonorrhea and 4890 from 
sj'philis. The Surgeon General also states that these figures are far 
short of the actual number, as it was formerly the custom of many 
surgeons to report only such patients as were incapacitated by their 
disease. In 1909 the total primary admissions for all diseases were 
38,735, of which number 11,064. were venereal patients. Gates be- 
lieves the prevalence of venereal disease in military service to be about 
the same as that existing in private life among young umuarried men. 
Mummery- reports that in the British nav}' venereal disease is not 
diminishing. He states that in 1906, in a total force of 108,190 men, 
13,193 suffered from venereal disease. During the year there was a 
total number of days' loss to the service of 316,631. The daily num- 
ber rendered inefTicient because of venereal disease was 867.46. 

The table supplied by Lieutenant-Colonel J. R. Kean,^ of the Medi- 
cal Department of the United States army, and Surgeon C. N. Fiske,' 
of the United States navy, to the Committee on Education of the 
Public to the Communicability and Prevention of Syphilis and Gon- 
orrhea, shows the following data: 

I'nited States army 
United States navy 
Japanese navy 
Briti.sli navy. . 
Hritish army 
Spanish army 
(lerman navy . 
Rua-iian army . 
Austrian army 
Japanese army 
Hel((ian army . 
Duteli army . , 
Prussian army 
Bavarian army 

10.5. U 


















139. 7.5 

' Kerr: Jour. Amer. Pub. Health Assoc, Marrh, 1911, p. 192. 

' Mummery: Brit. Med. Jour., August 1.5, 1908, p. 394. 

'K()l)er, G M.: Jour. Amer. Pul.. Ih'alth .Vssoc. ,\I:inli, 1911, p 



This Committee, in commenting on these statistics, states that, in 
its opinion, the high percentage of venereal diseases occurring among 
the Enghsh-speaking races is largely the result of the lax attitude 
adopted toward prophylaxis against these diseases in both England 
and the United States. 

Kean^ quotes the following figures as the admission rates given in 
the reports last obtainable for the important navies of the world : 


Mean Stbength 

Rate pes 1000 




Japanese. . 









83.0 = 

Kean' presents the following tables, showing the prevalence of 

venereal disease in the French, Austro-Hungarian, Spanish, and 

Russian armies: 







1903 ' 










1905 . 

























58 9 

1904 . . 

igo,--. . . 

190t) . 


















1908 ,... 

' Kean, J. R.: Military Surgeon, March, 1912, p. 261. 
•ci- 'P-^'^ i^ *'^'^ figure given in the official reports for " Malattie veneree." " Malattie 
sifihcho IS given separately, with a rate of 24 per 1000. It is not clear, from this context, 
whether the latter should be added to the former or is included in it. 

' Kean, J. R. : Loc. cit. 




Total Veneeeal Rate 










Although the statistics from army and navy reports refer only to 
men, there can be Uttle doubt but that they bear a close relationship 
to the prevalence of gonorrhea among women in the locahties in which 
the troops are quartered. 

Source of Infection. — The question of the source of infection is one 
of great importance to those interested in the moral or social prophy- 
laxis of venereal diseases. Numerous statistics have been compiled, 
and arguments, based on such findings, offered. In studying these 
statistics it should always be borne in mind that in different countries, 
and in different periods, many different customs and laws prevail, 
thus naturally affecting the results of such reports. Probably the 
most accurate and recent statistics referring to the source of infection 
among gonorrheal cases in this country are those compiled by Bier- 
hoff.' They are computed from cases of venereal disease occurring in 
New York, and only those cases that could accurately state the source 
of infection are included in the tables. The diagnosis in each case 
was based upon the microscopic or bactcriologic demonstration of the 


Pucll;i publica (street) 

" " (brothel) 

" " (kept) 

" " (unclassified) 

" " (friend) 

_ " " (mi.stress) 

Wives (who infected husbands) . . 

Married women and widows 



WorkinRwomen and servants. . . . 
Rc.spc(tul)li; (living with parents). 


Sexual perverts 


















































From t he foregoing it will be seen that, in 418 cases, or 79 per cent., 
of all first infections, the infection had its source in a prostitute. 

' IJierholT: New York Med. Jour., November 12, 1910. 




Puella publica (street 

" " (brothelj 

" " (kept) . . 

" " (unclassified) . . 

Wives (who infected 

Married women 




Respectable (li\'ing wnth parents) 
Workingwomen ; 




Factory girls . 


Hair-dressers - . 

Manicures . . 


Trained nurses 


Private secretaries . 

Cloak models . . 

Artist's models 





Companions . . . > 






















From Table 2 it will be observed that, in private practice, 370 
cases, or 64 per cent., of patients received their infection from prosti- 
tutes. Of a total of 1429 cases of gonorrhea, 1056, or 74 per cent., re- 
ceived their infection from public prostitutes. The following table 
shows the results obtained by Fournier in Paris and Bierhoff in Ber- 
lin and in New York as to the source of infection. 



(Paris, 1866) 

(Berlin, 1899-1900) 

(New York, 1910) 








Mistresses, actresses 


Mistresses, f 4a 

Actresses \ 57b 




Fiancees, widows, and di- 


Respectable women 







(») Under prostitute. {^) Under workingwomen. (<^) Under workingwomen. (^) Own 
wives, (c) Sexual perverts not included. 


The report of the Committee of Seven shows that, in cases in 
which the source of infection could be traced, 8053 were from public 
prostitutes, whereas 3915 were from clandestine alliances. The report 
also states that there were 988 cases of marital infection, seemingly 
indicating that nearly 33 per cent, of all venereal diseases found in 
private practice among women were communicated by the husband. 
In certain quarters it is believed that venereal disease comes as a 
form of punishment for sin. Every year thousands of innocents, 
usually wives, are infected. Statistics regarding venereal disease are 
notoriously inaccurate. Nevertheless, such carefully computed re- 
ports as those just quoted cannot fail to impress an unbiased mind 
with the fact that the public prostitutes in the city of New York 
today are by far the most prolific disseminators of venereal disease. 

]\Ienge' states that in Germany, where public prostitutes are under 
supervision, gonorrheal infection from this source is rather uncommon, 
but that the clandestine prostitute is a prolific disseminator of the 
di-sease. Blaschko- found, in lOO cases of gonorrhea in the male, that 
80 per cent, had contracted their infection from prostitutes. Diiring' 
is of the opinion that the prostitute is the most frequent source of 
infection. Neisser' states that nearly all cases of gonorrhea can be 
ultimately traced to prostitution. Finger^ and Lesser^ are of a similar 

General Prophylaxis. — The prevalence and ravages of venereal 
disease are, at the present time, so great as urgently to require the 
grave consideration of every physician and every student of sociology. 

There is no disease to which the axiom that "prevention is better 
than cure " applies more forcibly than to gonorrhea. Every gonorrheic 
is a source of danger: a danger far greater than accompanies the in- 
dividual affected with an ordinary infectious disease, for the latter is 
confined to his, if not by the severity of his disease, at least by 
law, during the period of his infectiousness. Gonorrheics, on the con- 
trary, mingle with their fellow-men, and thus often establish a sort of 
endless chain of infection. 

The pn)])hj'laxis of venereal disease is a subject thai is ;ipproacliod 
by most medical men w ith a degree of repulsion. Apart from the moral 
aspects that immediately present themselves, there is a general feeling 
that such subjects are best not discussed, and that, under any cir- 

' Mcngp, K.: H.andbiich dor Gcschlcchtslirankhciten, Vienna, I'JIO. 
' Uliwcliko, A.: Syphili.s und Prostitution vom Standpunkto dcr offcnlliclicii GcsuikI- 
hcitspflr'Kc, Berlin, WXi. 

• During: Prostitution und Gpschlccht.slcrankhpitcn 

• Ncisiter: Mittcilungcn d. fifspil.schaft furdie IkkiinipfuiiKdcrOeschlpclitskrankhcitcn. 
'Finger: Blennorrlioe dcr Spxualorgan. ' Lesser; Cliarit(5 Vortriige. 


cumstances, venereal disease affects chiefly the guilty. This view is 
particularly prevalent among the English-speaking races. As a con- 
sequence we have, in this country, the sorry spectacle of our boards of 
health ignoring a large and important group of diseases that are well 
known to be contagious and a menace to public and private health, 
and well recognized as one of the most potent factors in the production 
of race suicide. The explanation for this laxity will probably be found 
to rest on the difficult moral problems presented in this field of prophy- 
laxis, and on the absence of any certain specific method that would 
offer fair prospects of success. The double standard of morals is a 
strong factor in the production of venereal disease, but as the woman, 
in the event of pregnancy occurring, will always be the one to bear the 
outward and visible signs of her unchastity, there seems little likeli- 
hood of a change taking place in this respect. 

■ The subject of the prevention of venereal disease may be grouped 
under three broad headings: (1) General prophylaxis for those not in- 
fected ; (2) the method of dealing with prostitution ; and (3) the method 
of dealing with those already infected. There can be no doubt in the 
minds of all thinking persons that of all methods of dealing with this 
difficult and urgent problem, education offers the best, broadest, and 
most hopeful n:ieans of securing eventual success. Owing to the secret 
nature of venereal disease, this can best be accomplished in the hands 
of a broad-minded educational board, such, for example, as the Ameri- 
can Medical Association. The prevalence and ravages of venereal 
disease are not known to the general lay pubUc, in whose minds this 
group of diseases, and gonorrhea especially, is often regarded as a com- 
paratively mild lesion. If their extent and harmful influence were 
generahy recognized, a great step in advance in dealing with these con- 
ditions would be made, and the physician sought more readily for in- 
struction and aid. Christian,' in a recent paper read before the 
Section on Surgery of the Medical Society of the State of Pennsylvania, 
rather questions the advantages to be derived from this form of prophy- 
laxis. One example will be suflScient to prove the fallacy of such a 
view. Few, if any, men would have intercoiirse with a woman known 
to have gonorrhea or syphilis. Statistics have amply demonstrated 
that a large proportion of pubHc prostitutes are affected with a venereal 
disease of some kind. It would be conservative to state that 50 per 
cent, of all public prostitutes in the United States were the incumbents 
of an uncured venereal disease. The majority of these are chronic 
cases, and do not by any means always transmit their infection to 
their partners. Nevertheless, few individuals would care to jeopardize 

' Christian, H. M.: The Pennsylvania Med. Jour., July, 1912, p. 788. 


themselves were they truly cognizant of the fact that one out of every 
two inmates of houses of ill-fame was affected with a communicable 
disease. Too often such information is considered by men as ema- 
nating from a moral, rather than an actual, cause, and it is believed to 
be an exaggeration, and, therefore, is disregarded. Bigelow^ writes 
that sex education will not enforce universal morality in conformity 
with our accepted code, but it will help in many decisive battles with 
sex instinct. To all those who see nothing in the movement because 
it will not solve all the sex problems that have created a demand for 
special instruction, he replies by pointing out that general education 
makes more efficient and better citizens, but also often fails. 

The age of consent is an important matter in the prophylaxis of 
venereal disease. In many States the fixed age is too young. In 
Georgia and Mississippi the age of consent is ten years; in 7 other 
States it is fourteen years; in Texas, it is fifteen years; in Illinois and 
in 21 other States, it is sixteen years — thus the average age of consent 
in 32 states is sixteen years or un,der. All high school children should 
receive instruction regarding venereal disease; in many States this 
is now included under the heading of general hygiene. With a little 
circumspection such instruction can be shorn of all objectionable 
features. The exact age at which children should receive this instruc- 
tion is a point to be carefully considered. 

Boys of thirteen or fourteen and girls a year or two older should 
certainly have some knowledge of sex hygiene, and it would be a 
distinct advantage for them to obtain such knowledge from a reliable 
source, rather than to depend on the present method of obtaining a 
scattered and distorted view from older children or even more harmful 
sources. It is proba})le that such institutions as the Red Cross Society 
in this country, and the First Aid Instruction in England, could be 
utilized with advantage to teach children the necessary facts regarding 
venereal disease. Lectures to boys and girls should, of course, be 
given separately, the boys receiving their instruction from a male and 
the girls from a female teacher. Such work has already been begun 
in this country. Morrow^ states that a collective investigation which 
is now in progress, but not yet completed, undertaken by a committee 
of the National Educational Association, shows that, in 138 schools 
and colleges in the United States, personal and sex hygiene is taught 

Education along broad lines could also be given as a part of each 
college curriculum. In this connection it is interesting to observe that 

' Uigclow, M. E.: Jour. Amer. Med. Assoc, October .5, 1912, p. 1312. 
2 Morrdw, P. A.: New York Med. Jour., March 23, 1912, p. 577. 


this step has already been taken in Austria. Some years ago the 
students, on entering an Austrian university for the first time, were 
handed a leaflet containing, in clear and instructive language, warnings 
against imprudence in sexual intercourse, and explaining the dangers 
of gonorrhea and syphilis, both to the affected subject and to the wife 
and offspring. The next step in advance consisted in the instruction 
of the student before he entered the university. In the higher classes 
of the preparatory schools, in which the pupils were between sixteen and 
eighteen years of age, teaching of anatomy gave a good opportunity 
for scientific instruction on this point. At present the instruction on 
sexual subjects is given by the school physician, who uses his discretion 
as to age at which it shall be begun. As a rule, such instruction is 
given when the pupils are about fourteen years of age. 

Lectures, preferably illustrated by lantern-slides, should be delivered 
to various business and workingmen's associations, unions, and large 
industrial institutions. Great care should be exercised to have such 
lectures free from all moral teaching and the expression of virtuous 
platitudes. The audience should be told that continence is entirely 
compatible with health, and the dangers and prevalence of venereal 
disease should be dwelt upon. The Young Men's Christian Associa- 
tion would be . a vehicle of great aid in the advancement of such an 
educational cause. If a campaign of this kind were waged by some 
world-wide educational body, such as, for example, the American 
Medical Association, various periodicals could be utilized, and would 
be of the utmost benefit as disseminators of knowledge. Personal 
hygiene, exercise, and cleanliness should be encouraged. There is no 
doubt that a certain class of modern literature and art, together with 
questionable plays, form a very decided detrimental factor in personal 
morality. The Board of Censors recently instituted in England is 
doing good work along this line. That the importance of sexual 
education is recognized in Germany is instanced by the prominence 
given to this subject in the Internationale Hygiene Ausstellung in 
Dresden, of 1911. 

The interminghng of the sexes as the result of the modern trend of 
business life is detrimental to the morality of women. Other impor- 
tant factors tending toward sexual impurity, and therefore toward the 
propagation of venereal disease, are certain economic problems — ■ 
the influence of crowding, labor competition, faulty home environ- 
ment, migration to cities, child labor, ignorance, and inadequate 
moral training. The advertising of unlicensed practitioners of medi- 
cine, the patent medicines, the baby-farms, massage establishments, 
and the abortionists, all have an undermining influence on pubUc 


morals. All these factors must be taken into consideration in attempt- 
ing to reduce the prevalence of venereal disease. Many of these are 
insignificant in themselves, but when taken together, are of the utmost 
importance. Sane educational pamphlets are also of value in teaching 
the public the dangers of venereal disease. The educational problem 
is so large a one that it could be handled with any degree of effective- 
ness only by the appointment, bj^ some leading body, of a number of 
committees. Wolbast^ has suggested a Committee on High Schools, 
a Committee on Workingmen and Women's Labor Unions, and Uke 
organizations, a Committee on Army and Navy, a Committee on Shops 
and Factories, a Committee on Churches and Religious Bodies, a 
Committee on Young People's Clubs and Settlement Houses, and a 
Committee on Fraternal Orders. Such committees could undoubtedly 
do much good. We think, however, that the army and navy are quite 
competent to handle their own affairs. A Committee on Publi- 
cation would, without doubt, be of great advantage. Phj^sicians 
could also become valuable disseminators of knowledge. Since the 
organization, in February, 1905, of the American Society of Sanitary 
and Moral Prophylaxis, much praiseworthy work along educational 
lines has been accomplished, a detailed description of which is given by 
Morrow.- Branch societies have been established in Philadelphia, 
Detroit, Chicago, Milwaukee, Jacksonville, Indianapolis, Baltimore, 
St. Louis, Spokane, Portland, Denver, and many other cities. In 
Germany the Association for the Prevention of Venereal Disease, of 
which Professor Neisser is the President, has accomplished much good 
in this way. This society numbers over 5000 members, and has 
distributed over 5,000,000 pamphlets. National organizations for 
the prevention of venereal disease also exist in France, Austria, Den- 
mark, Italy, Hungary, and Belgium. The oldest organization is the 
Teleia (literally translated, meaning "Venus"), of Budapest, which 
is fifteen years old. Sweden has no organization, but the physicians 
have accomplished much in the way of education by the distribution 
of pamphlets. It has been claimed by the opponents of educational 
prophylaxis that it is ineflicient, and the statement has been made that 
venereal tlisease is prevalent among medical students, a class of young 
men who are comparatively well educated regarding venereal disease. 
No proof has, however, been adduced to show that this is so. As a 
matter of fact, venereal disease among medical students is compara- 
tively infrequent, and even if it were not, this would be no argument 
against education. The history of medicine shows that all great steps 

' Wolbast: Me<l. und Surg. Jour., September V.i, 190H, p. 280. 
' Morrow, P. A.: New York Med. Jour., March 23, 1912, p. 577. 


in the prophylaxis against disease have been accomplished along 
educational lines. As examples of this may be mentioned tuberculosis 
and yellow fever. Perhaps, however, the greatest cause of lapse from 
virtue on the part of the average young man or woman is alcohol, 
and the law regarding the selling of this to ndnors should be strictly 
enforced. It is a well-known fact that a large proportion of men are 
under the influence of alcohol when they become infected. Alcohol 
in any form, and especially in the young, tends to weaken the moral 
fiber, to break down natural restraints and barriers, and to cause 
forgetfulness or disregard of the dangers of illicit intercourse. The 
cafes and saloons that cater to this class of trade should receive rigid 
supervision, and any infringement of the present law should be severely 
dealt with. These places — and they are numerous in all large cities 
— are direct factors in the production of inestimable harm and the 
ruin of many young girls. The Chicago Vice Commission,^ in its 
recent report, strongly recommends rigorous supervision of all such 
resorts. An excellent movement is now being made in some States to 
teach public school-children the evils of alcohol. 

The frequency with which gonorrhea is contracted by intoxicated 
individuals is well known. Moller- gives some interesting data on this 
subject. He questioned 661 patients concerning the source of their 
infection. At 'least 20 per cent, of the number gave information 
sufficiently clear to make investigation of the source possible; 67 per 
cent, could give no information, having been intoxicated at the time of 

Although infection by means other than sexual intercourse is rare 
in any form of venereal disease, and especially is this so of gonorrhea, 
nevertheless steps should be taken to see that public lavatories be so 
constructed and cared for that the likelihood of transmitting contagion 
would be reduced to the minimum. The fact should never be lost 
sight of that it is the young who are most likely to become infected. 
Thus, LePileur states that, of 718 women affected with venereal disease, 
62.9 per cent, were between sixteen and twenty years of age at the time 
of infection. Storer^ found, of 140 single women suffering from 
venereal disease who applied for dispensary treatment, only 14 were 
over thirty years of age, while 62 per cent, were between seventeen and 
twenty-two years old. Among married women, the average age was 
somewhat greater. 

' Social Evil in Chicago, Report of the Vice Commission, 1911. 

' Moller, M.: Zeitschr. f Bekampf. d. Geschlechtskrankh., Leipzig, vol. v, part 7. 

' Storer: Amer. Jour. Pub. Hygiene, 190S, p. 52. 



In 1910 the Committee on Education of the Public as to the Com- 
municabiUty and Prevention of Gonorrhea and Syphihs reported at the 
thirty-eighth annual meeting of The American Public Health Associa- 
tion, and presented the following suggestions: The Committee recom- 
mended: (1) The recognition, studj-, and control of the prevalence of 
these, as with other communicable diseases; (2) an educational cam- 
paign for parents and children, the teaching to be strictlj' medical 
(non-moral) — (a) Pamphlets; (b) utilization of State Health Depart- 
ment; (c) State Health Department to make effort to awaken interest 
in venereal disease among phj-sicians; (d) State Health Department to 
send out paid and trained lecturers to address special meetings of 
parents, health officers, medical men, teachers, and others in schools, 
colleges, churches, etc., on these and other preventable diseases; (e) 
State Health Department to encourage the organization of associa- 
tions for prophylaxis; (J) health departments to interest and provide 
for authorities having charge of educational curriculum in public and 
private schools — (1) By the introduction of biology into the graded 
courses of all schools; (2) to provide instruction in sexual matters for 
students of the upper grades; (3) by special instruction to students 
who are to become instructors. To impress upon presidents, deans, 
preceptors, and teachers the necessity of exercising their influence on 
students in reference to the communicability of gonorrhea and syphihs, 
and to inculcate a morale of protection among college fraternities; (g) 
to utilize the public press for the proper occasional presentation 
of the subject, and to discourage the display of advertising matter 
that encourages the exposure to these diseases; (h) to utilize 
church clubs, and especially mothers' clubs, for the instruction of 
parents; (i) health departments to recommend the enactment of 
laws for — (1) Physical inspection and segregation of prostitutes; (2) 
notification and report (by number, if desired) of venereal disease; 
(3) physical examination of men before marriage, male applicants for 
marriage licenses being required to submit to examination by a duly 
qualified physician for the purpose of ascertaining whether said 
applicants are free from venereal disease; (4) to make it a crime to 
spread venereal disease; (5) keeping open free night dispensaries 
and maintaining special dispensaries and hospitals for the treatment 
of diseases; (6) advocacy of temperance on account of the rela- 
tionship existing between alcoholism aiul venereal diseases; (k) 
advocacy of personal cleanliness and venereal prophylaxis; {I) 
advocacy of early marriage. These recoimnendations were adopted. 



1. Bierhoff: New York Med. Jour., November 12, 1910. 

2. Clock: Amer. Jour. Dermat., 1907, p. 487. 

3. Doleris: La Gynecologie, November, 1910. 

4. Emley: Kansas Med. Society, 1908, p. 428. 

5. Fiske: Jour. Amer. Pub. Health Assoc, March, 1911, p. 181. 

6. Forchheimer: Bost. Med. and Surg. Jour., July 30, 1910, p. 161. 

7. Grubbs: Military Surgeon, 1909, p. 576. 

8. Kerr: Jour. Amer. Pub. Health Assoc, March, 1911, p. 192. 

9. Hepburn; Yale Med. Jour., 1908, p. 168. 

10. Hoff: Military Surgeon, 1909, p. 732. 

11. Holton: Jour. Amer. Med. As.soc., March 11, 1905. 

12. Johnson, J. T.: Jour. Amer. Med. Assoc, March 11, 1905. 

13. Litclifield: Jour. Social Hygiene, December, 1909, p. 174; Jour. Amer. Med. Assoc, 

February 26, 1910. 

14. Morrow: Maryland Med. Jour., 1908, p. 260. 

15. IMummery: Brit. Med. Jour., August 15, 1908, p. 394. 

16. Munson: MiUtary Hygiene, p. 823. 

17. Robb: Trans. Amer. Gyn. Soc, 1906. 

18. Sanger: Hist, of Prostitution. 

19. Social Evil in Chicago: Report of the Vice Commission, 1911. 

20. Storer: Amer. Jour. Pubhc Hygiene, 1908, p. 52. 

21. VonTophy: Military Hygiene, p. 830. 

22. Wolbast: Med. and Surg. Jour., September 13, 1908, p. 280. 

23. Amer. Jour. PubUc Hygiene, 1908, p. 39. 

24. Report Com. State Board of Hygiene, Washington, 1905 

25. Report of the American Public Health Association, thirty-eighth annual meeting, in 
the Jour Amer. Pub. Health Assoc, March, 1911, p. 162. 

26. Report of the Committee of Seven, Med. News, December 21, 1909. 


The history of prostitution can be traced back to the earliest 
traditions of the human race. Moses attempted to eradicate prostitu- 
tion, but without success. Among the early Greeks and Romans 
prostitution was rife. As we follow the progress of time among the 
peoples of the world, so can the history of prostitution be followed from 
age to age. As surely as a community of any size is gathered together 
in a given locality, as surely will prostitution make its appearance. 
The number of prostitutes per thousand of the population varies with 
different races and at different times. It bears, however, always a 
direct relationship to the number of able-bodied unmarried men in any 
given community. 

Although Flatau^ and others have amply proved that continence 
is entirely compatible with health, it is, nevertheless, impossible 
to formulate laws that will eradicate or even control sexual desire — 
one of the strongest if not the strongest instinct of the human race. 
Often more powerful than the instinct of self-preservation, the 
sexual appetite may be provocative both of inestimable good and of 
much harm. Were it not for this passion, the world would quickly be 
depopulated; on the other hand, just as certainly, a very definite 
proportion of sorrow and crime can be laid at its door. As a result of 
many economic and social factors, "there has arisen in society a figure 
which is certainly the most mournful, and in some respects the most 
awful, upon which the eye of the moralist can dwell. That unhappy 
being whose very name it is a shame to speak ; who counterfeits, with 
a cold heart, the transports of affection, and submits herself as the 
passive instrument of lust; who is scorned and insulted by the vilest 
of her sex, and doomed, for the most part, to disease and abject 
wretchedness and an early death, appears in every age as the perpetual 
symbol of the degradation and sinfulness of man. Herself the supreme 
type of vice, she is ultiinatcij^ the most officicMit guardian of virtue. 
But for her, the unchallenged jiurit}' of countless hapjiy homes would 
bo polluted, and not a few who, in the pride of tlieir unt empted chastity, 
think of her with an indignant shudder, would have known tiie agony of 

' Flaluu, G.: Scxucllc Ncurastlicnic, Berlin. 



remorse and despair. On that one degraded and ignorant form 
are concentrated the passions that might have filled the world with 
shame. She remains, while creeds and civilization rise and fall, the 
eternal 'priestess of humanity,' blasted for the sins of the people" 

The relation that prostitution bears to gonorrhea needs no confir- 
mation. Huber,- in the routine examination of 533 sick and well 
prostitutes, found that 59.6 per cent, had gonorrhea. Prowe^ detected 
gonorrhea in 76.9 per cent, of a series of prostitutes examined in San 
Salvador, Central America. While Dreier and SlachoW found positive 
proof of gonorrhea in 220 of 1021 inscribed prostitutes, and a suspicion 
of the disease in 94 additional women. Bendig= presents the following 
statistics showing the frequency of venereal diseases among prostitutes 
of certain cities of Germany: 

_ Population, 
"-'"' Last Censds 

Ndmber of 


(Venereal Dis- 
eases Found) 



not under 



Berlin 2,040,222 

Hamburg 809,090 

Munich ;' 538,-393 

Drestlen 514,283 

Cologne 428,503 

Frankfurt a. M. . . . 334.951 
Hanover , 250,632 

Stuttgart ' 249,286 

Chemnitz 244,405 

Charlottenburg . . . 239,512 








28 ^ 




Not given 

About 700 



500 to 700 

300 to 350 


20 per 






80 per 





There is every reason to believe that gonorrhea is extremelj^ prev- 
alent in the prostitutes of the United States, although, on account of 
our methods of dealing with this subject in this comitry, no accurate 
data are obtainable. 

As Lawrence F. Flick has well said, in approaching the subject of 
prophylaxis of venereal disease, we should separate the moral from the 
sanitary side. It is sheer absurdity to assert that prostitution can 
ever be completely eradicated. The sexually frigid or superannuated 
may attempt to make laws aiming to govern the hot blood of youth, 

' Lecky: History of European Morals. 
= Huber: Wien. med. Wochenschr., 1898, p. 24. 
' Prowe: Cent. f. Gyn., 1901, vol. xxv, p. 82. 

' Dreier and Slachow: Die Prostitution, Bremen, in Hygienischer Beziehung, 1907. 
' Bendig: Zeitschrift fur die Bekampfung der Geschlechtskrankheiten, vol. xxii. No. 1; 
also Bierhoff, P.: New York Med. Jour., November 16, 1912, p. 1010. 



but such laws can never be enforced. The question of prostitution 
is one governed largely by the great law of supply and demand. 
The high cost of living is undoubtedly an important factor to be con- 
sidered in studying the question of prostitution at the present day. 
Too often the increased cost of living precludes or postpones marriage, 
and leaves in everj^ city a large number of healthy individuals of both 
sexes whose normal and not infrequently excessive sexual desires have 
no legitimate outlet. There can be no argument regarding the 
existence of prostitution. It is estimated that in New York today 
there are between 50,000 and 75,000 prostitutes, and that $125,000,000 
is spent annually by the population of the civilized world for illicit 
sexual congress. 

Kelly' estimates that venereal diseases cost America three billion 
dollars a year. These figures seem to be underestimated, rather than 
exaggerated. In the report of the recent Chicago Vice Commission 
it is estimated that the profits accruing from prostitution in that city 
alone amount to $15,000,000 annually. The important question to 
decide is, What attitude shall be taken toward prostitution bj^ those 
interested in the suppression of venereal disease? In deciding this 
question many important details must be considered. The Committee 
of Fifteen recommended — (a) That prostitution must be driven out of 
tenements and apartment houses and excluded from the houses of the 
poor; (h) that it must not be segregated, for such localities become 
areas of crime; (c) that all public manifestation of prostitution must 
be suppressed. There can be no question as to the expediency of the 
foregoing suggestions, w'ith the one exception perhaps of the second. 
The belief that prostitution can ever be entirely abolished is Utopian. 
From time immemorial attempts have been made in many countries 
to eradicate it, but always without success, as witness the following 
instance: Many years ago, when Philadelphia was a factor in the 
shipping industry, the better class of citizens rose up against this evil, 
and brought their influence to bear on the police department, so that 
the closure of all, or nearly all, the houses of prostitution was effected. 
It was not long, however, before a petition was laid before the city 
fathers asking that the severity of the police cf)ntr()l be relaxed, since 
it became unsafe for respectable women to walk the streets.- In 1G07 
Berlin closed all the brothels within the city, but was forced to reopen 
them. Similar failures followed efforts in France, in 15G0, in England 
under the reign of Henry VIII, and later in Australia. In Pittsburgh, 
in ISOl, an attempt was made to close all houses of prostitution, but 

' Kelly, II. A.; .lour. Amer. .Med. Assoc, October 0, 1912, p. i:n2. 
- 'Pile .iiilliiir (Hicslioiis I lie vcnicily of the liiltcr .statcinciil. 


this failed. A year later, in New York, a similar effort was made, 
with the result that vice was disseminated throughout the city. 
Nearly every city of any size in the United States has at times 
been swept by waves of moral virtue that have resulted in crusades 
against the so-called "social evil." How useless, and often actually 
detrimental, such efforts have always proved is a fact well known to 
students of sociology and those interested in the prophylaxis of 
venereal disease. 

As has previously been stated, much diversity of opinion exists as to 
the best methods of handling the difficult problem of prostitution. In 
this connection, however, it is interesting to observe the unity of opin- 
ion that exists in the recent reports issued by the Police Commissioner 
of Boston, the Committee of Fourteen in New York, and the Mayor's 
Vice Commission of Chicago. These committees are agreed on the 
need of stern repression of overt vice ; of a more wide-spread dissemina- 
tion of medical knowledge among lay adults; of sound, thorough 
education of the young in the fundaments of sex hygiene; of strict 
enforcement of individual responsibility; and of the paying of a 
"living wage" to girls employed in the industries. They also recom- 
mend the abolition of the rear door and hotel features in connection 
with the saloon. Of especial significance is the fact that the com- 
mittees are unanimous in the belief that crusades, and the like, are 
harmful, particularly when conducted, as they often are, by misguided 

The question arises. Are the regulations suggested by these com- 
mittees sufficient to govern the evil, or is the regulation or supervision 
of prostitution by municipal authorities advisable? Before deter- 
mining so important a point, let us review briefly the methods in force 
in the various civiUzed countries to control this evil. 

Germany. — Prostitution is recognized as a necessary evil, and 
municipal attempts are made to control it. The method employed 
varies somewhat in the different cities. In general, the principle is 
somewhat as follows: A special pohce department has been organized 
to control prostitution. These police officers are known as the "Sit- 
ten-Polizei," and are divided into two groups — one to control the 
prostitutes, the other being the medical department. The work of the 
police department consists in a general supervision of the prostitutes. 
If a woman is seen soliciting in the streets she is questioned and 
cautioned. If, in spite of this warning, she is again found soliciting, 
she is brought to the police station, where she is again warned, and 
given a booklet containing information concerning institutions and 
organizations to which women may apply for assistance and medical 


aid, and describing the dangers of illicit intercourse, venereal diseases, 
and their method of spread, etc. If she is under age, notice is sent to 
her parents. If, despite these warnings, she persists in her course of 
life, she is examined, and if found to be diseased, she is sent to a hos- 
pital, where she is detained until the period of her infectiousness is 
over. If she is found to be free of disease, she is inscribed, and given 
a book that is countersigned at each medical examination. No girl 
under eighteen j-ears of age is inscribed, although if she is found to be 
infected she may be sent to a hospital for treatment. These police 
wear plain clothes and perform their duties unostentatiously. If 
arrest is necessary, a closed cab is employed. The police records are 
available only to the "Sitten-Polizei." This department occupies 
separate buildings having private entrances, exits, and waiting-rooms 
for the women. The entire proceedings are conducted with as little 
publicit}^ as possible, and the women are well treated. The city of 
Berlin (2, .500, 000 population) is divided into twelve districts, each of 
which has a physician in charge. All first examinations are performed 
by a female physician, who receives 12,000 Marks per annum; the 
physicians in charge receive 24,000 ]Marks each. No woman can be 
inscribed who can show that she is earning money, however little, by 
means other than prostitution. The attitude of the "Sitten-PoUzei" 
is governed, even to the minutest details, by printed rules. These 
rules make it easy for women to have their names removed from the 
inscribed lists and police regulation if they show evidences of wishing 
to reform. 

In Dresden the medical examination is conducted in a most 
scientific maimer. It consists of a thorough general examination, and 
the making of smears and cultures from scrapings from the cervix and 
urethra. The prostitutes are divided into three classes: Class 1 
consists of all women under twenty-four years of age; of all women 
who have not been under control for one year, and of all other women 
who are thouglit Ukely to be a special source of infection. The women 
belonging to this class are examined twice a week. Class 2 consists 
of women between twenty-four and thirty-four years of age. These 
are examined once a week. Class 3 consists of women over thirty- 
four years old. These are examined every two weeks. Definite 
hygienic regulations are recommended to all prostitutes. In addition, 
there are certain special laws that they must observe. These forl)id 
intercourse with minors. The prostitute is enjoined to dress decently, 
and to conduct herself with decorum when in iniblic. She must not 
frcciuent c(>rtain parks and streets. She nmst not show lierself at the 
windows of her dwelling, nor must she reside near schools or cliiirches. 


These are but a few of the many rules laid down to her. In Berlin, 
Dresden, and Leipzig brothels are not tolerated. In Hamburg this is 
not the case, and segregation is inforced. In the last-named city there 
is a sick fund to which all proscribed prostitutes subscribe. This fund is 
used to defray the expenses of the women that require medical treat- 
ment . There is in Germany a party known as the Abolitionists. These 
demand a medical certificate from each man about to marry, and regard 
it as an intolerable invasion of the personal liberty of women to demand 
that a prostitute, who may daily infect a dozen men, should be com- 
pelled to submit to systematic medical examination. In Dresden, since 
the regulations first described have been in force, gonorrhea has 
diminished 40 per cent, among the women examined (de Forest^). 

IMenge^ states that gonorrhea is somewhat uncommon in the 
registered prostitutes, and that it is the clandestine or secret prostitutes 
who are the real disseminators of the disease. Excellent results have 
also been obtained in Hamburg. As the result of the regulations 
good order is maintained throughout the city, a state of affairs in 
striking contrast to the conditions that exist in the Prussian city of 
Altona, an immediate suburb of Hamburg, and separated from the 
latter only by an imaginary line. Of the venereal cases seen in the 
hospitals of Hamburg, 70 per cent, came from Altona (Bierhoff^). In 
this city no regulation is in force. Neisser and Blaschko^ declare that 
regulation is of little value. In Berlin, from 10 per cent, to 25 per 
cent, of the prostitutes are under control, and this is probably the 
proportion in most of the large German cities. 

Kelly^ states that in Berlin there are 30,000 prostitutes, of whom 
2016 are under control; in Vieima, 30,000, of whom 3063 are under 
control; and in Paris, 45,000, of whom 6000 are under control. Bier- 
hoff* states that by the present system in 1911 there were 3024 sources 
of infection withdrawn from circulation in Berlin alone. Weidanz' 
states that venereal diseases have steadily decreased since the inaugura- 
tion of the present system. 

There is in Germany a National Association for the prevention 
of venereal disease, known as the Deutsche Gesellschaf t zur Bekampf- 
ung der Geschlechtskrankheiten (D. G. B. G.). Tliis is an active 

' de Forest: New York State Jour. Med., October, 1908, p. 516. 

= Menge, K.: Handbuch der Geschlechtskrankheiten, Vienna, 1910. 

' Bierhofif: New York Med. Jour., August 17, 1907; also ibid., March 25 and April 1, 
1911. . 6 , , 

■• Blaschko, A. : Syphilis und Prostitution vom Standpunkte der offentlichen Gesund- 
heitspflege, Berlin, 1893. 

* Kelly, H. A.: Med. Press and Circ, August 14, 1912, p. 158. 

" Bierhoff, F.: New York Med. Jour., September 21, 28, and October 5, 1912. 

'Weidanz: Quoted by Bierhoff: hoc. cil. 


orgamzation, many eminent men and women being eni'olled in its 
ranks. Thirtj' branch societies are scattered throughout Germany. 
The dues are 3 Marks. Each member receives monthly hterature 
regarding the work accomplished by the Society. This organization 
has done much in the way of spreading education, increasing hospital 
accommodations for venereal patients, and making venereal disease 
an important branch of study in the various medical schools. The 
Society has distributed a large number of educational pamphlets. 

For further information regarding the methods of dealing with 
prostitution in Germany the reader is referred to the exhaustive 
papers upon this subject by Bierhoff and de Forest. 

Xoricay. — In this country much is being accomplished in the way 
of securing efficient prophylaxis. Venereal diseases are reportable; 
they are treated at public expense, and treatment is made compulsor3\ 
Physicians must inform their patients of the nature and contagious 
character of their disease. Patients are rendered liable for the expense 
of treatment of, as well as for damages suffered by, those whom they 
may infect. The person from whom the infection is derived is sum- 
moned to the sanitary office, and asked to submit to an examination. 
If they accept, and venereal disease is discovered, free treatment is 
furnished, if desired. If, however, the examination is refused, the 
individual must bring a certificate from a physician stating that he or 
she is either free from disease or is undergoing treatment. If a venereal 

disease is present, the patient must sign the following form: "Dr. 

has told me that I am suffering from fnanie of disease), a contagious 
disease. He has fully explained to me the dangers of the disease with 
regard to myself and mj^ associates and its probable duration, and has 
made clear to me that I must remain under treatment until he gives me 
a certificate to bring to this office that I am well and no longer a source 
of contagion. I know that if I have sexual intercourse during this 
time, whether I transmit the disease or not, I am liable to be punished, 
under Section XX of the laws of Norway." If, after signing such a 
form, the patient indulges in intercourse before he or she is pronoimced 
free from contagion Ijy the attending physician, the law is invoked. 
A monetary iiidcnmitj' maj' legally be claimed l)y any man or woman 
who has knowingly been exposed to venereal disease, whetlier or not 
they have been infected. Those in chai'ge of tlic sanitary offices are 

Sivcden and Finland. — These countries have adopted systems mod- 
eled somewhat after that of Norway. In Sweden segregation is in 
force. Christiania and Copenhagen have abandoned police regulation. 


In Stockholm regulation is in force, but of the 3000 or 4000 prostitutes 
said to be in the city, not more than 500 are under control. 

In 1903 the Swedish government appointed a committee to study 
and report on the question of prostitution. After seven years it de- 
clared itself against reglementation.^ This committee stated that — 
"The objections which are brought to bear against regulation from a 
social, moral, and legal standpoint are so formidable that the useful- 
ness which, from a sanitary point of view, it might possess, is not al- 
lowable as a consideration for its retention." 

Holland and Denmark have abandoned police regulation. In the 
latter country compulsory notification by number of venereal diseases 
is in force. There are also numerous institutions in which free treat- 
ment may be obtained. 

England. — In London, after a desultory attempt at police regula- 
tion, the effort was abandoned. At present no attempt is made at 
police regulation. The transmission of venereal disease by illicit inter- 
course is not an actionable offense, provided the congress has been 
voluntary, even though it can be shown that there was intentional and 
wilful concealment of the disease; nor is there any legal offense if the 
husband infects his wife or the wife her husband. 

France. — In France prostitutes are under control. The system 
represents a combined effort on the part of the administration and the 
medical authorities to render the practice of prostitution less dangerous 
to the public health. A special corps of police is employed. Any 
woman in the streets suspected of prostitution may be arrested. If 
it can be proved that she is a prostitute, her name is inscribed in a 
special register, and she is given a card, which is countersigned at each 
medical examination. Inmates of brothels are examined weekly, and 
others are obliged to report for examinatioii every two weeks. When 
found to be diseased, the prostitute is sent to a special hospital, St. 
Lazar, where she is detained until the infectious stage of her disease 
has passed. It has been estimated that there are over 100,000 prosti- 
tutes in Paris. The system has been in operation for over fifty years, 
and has been fairly efficient, as is proved by Fournier's statistics, which 
show that only 7.08 per cent, of infected men received their contamina- 
tion from public prostitutes. 

Italy. — This country provides numerous free beds for her venereal 

Japan. — In Japan prostitutes are strictly segregated. The persons 
who conduct the brothels employ physicians to make weekly physical 
examinations of the inmates. These examinations are thorough, 

' Mitt, d, Deutsch. Gesellseh. z. Bekampf. d. Geschlechtsk., April, 1911. 



scientific, and modern. These persons also contribute toward the 
maintenance of the hospitals where contaminated prostitutes are con- 
fined and treated during the period of their infectiousness. The Jap- 
anese sj'stem is maintained not so much by law as by public sentiment. 

Austro-Himgary. — In Budapest from 1700 to 2000 prostitutes are 
under control. These constitute about 40 per cent, to 50 per cent, of 
the total number. This control is exercised over prostitutes from all 
classes, differing radically in this respect from the German cities and 
from Paris, where the inscribed prostitutes are chiefly of the lower 
class. In Budapest registration is voluntarj^ but constitutes the only 
means by which a prostitute can avoid arrest and punishment. The 
control is associated with medical examination, which, however, is 
less thorough than in Germany. 

According to Guiteras,^ registration of prostitutes is in force in 

United States. — In this country the method of dealing with the evil 
of prostitution varies quite markedly in different localities, owing to 
the State laws. In general, the feeling is strongly against any form 
of official recognition. Supervision has been attempted in a few 
cities, but has never met with the success hoped for by its advo- 
cates. In Detroit regulation was in force for one year and was then 
abandoned. At that time Detroit had a population of 400,000. It 
contained about 125 houses of ill fame, having 500 registered in- 
mates. The great prevalence of venereal diseases in New York has 
recently forced the authorities to take some action to remedy the evil. 
As a result, the Page Bill, Paragraph 79, in 1910 become a law. This 
law provided for "the medical examination, by a woman physician of 
the Board of Health, of all females convicted of prostituting or solicit- 
ing, and the commitment of persons of this class who may be found 
affected with any venereal disease which is contagious, infectious, or 
communicable, to public hospitals, having a ward or wards for the 
treatment of the disease with which she is afltlicted, for detention and 
treatment for a minimum period fixed by him in the commitment and 
for a maximum period for which she is committed to such an institu- 
tion. She shall be discharged and released from custody upon the 
written order of the officer in charge of the institution to which she is 
committed, upon the certificate of a physician of such institution or of 
the department of health that the prisoner is free of any venereal dis- 
ease which is contagious, infectious, or communicable. If, however, 
such prisoner shall be cured prior to the expiration of such minimum 
period for which she was committed, she shall be transferred to the 

> Guitcras, R.: Amer. Jour. Pub. Ileallh, .March, 1912, p. 204. 


workhouse and discharged at the expiration of such minimum period" 
(Bierhoff). No certificate of any kind is given to the woman. Ac- 
cording to the Board of PoUce Magistrates, the law was effecting some 
good. After having been in force about a year, the Page law was 
declared unconstitutional. As a result, examinations were suspended 
in June, 1911. Schenck^ states that regulation is in force in San 
Francisco and in Norfolk. He beUeves that the system has been 
satisfactory in the latter city. In Salt Lake City prostitution is 
ignored (1909), but the officials exact a Ucense under the name of a 
bond. There are laws against prostitution, but these are not inforced. 
Segregation is practised to a certain extent. The modus operandi of 
the bond is as follows : Every month the prostitutes are arrested and 
are then bonded for $10.00 or $15.00 a head to appear and answer the 
charge of vagrancy. As they never appear, the bond is forfeited, and 
the money goes into the city treasury, and is equivalent to a Ucense 
fee. A somewhat similar custom is — or at one time was — in force in 
New Orleans. In the majority of cities of the United States prostitu- 
tion is not officially recognized and is considered an offense. Unless, 
however, it becomes too flagrant, no efforts are usually made to suppress 
the traffic. The fact that it is illegal opens an avenue for "graft" 
by petty police officers that practically amounts to a license system. 
Instead, however, of swelling the city treasury, the money remains in 
the hands of the police and ward politicians. Owing to the prevalence 
of venereal disease in the Philippines, it has been found necessary, in 
some localities,, to issue a certificate of health to the women practising 
prostitution. The question as to the advisability of securing official 
recognition of prostitution in the United States is an extremely grave 
one, and a decision should not be reached before a careful considera- 
tion of all the facts bearing on the case is made. Much has been writ- 
ten on this subject, both in Europe and in this country. Many of those 
antagonistic to the official recognition of prostitution are influenced 
largely by the moral aspects of the question. The following is a con- 
densed summary of the arguments that have been advanced for this 
official recognition : 


1. Prostitution is immoral and should, L This is undoubtedly a strong argument. 

therefore, not be licensed. Many authorities believe that regula- 

tion is the lesser of the two evils. 

2. Regulation does not regulate, and segre- 2. Efficient regulation is a matter of money 
gation does not segregate. Regulation and can be obtained by paying for it. 
has been in force for fifty years in Paris Note the excellent results obtained in 
and venereal disease is still prevalent. Germany. If regulation had not been 

' Schenck, P. S.: Jour. Amer. Med. Assoc, November 23, 1912, p. 1916. 



Arguments For and Agaixst the Official Regulation of PROSTmrrioN — (Continued) 
Regulation has been abandoned in believed to be of ser\-ice, it would not 

many countries. This would not be have been maintained for fifty years 

the case if it had given satisfactory in Paris, 


3. Regulation would tend to augment 
poUce "graft." 

4. One of the greatest protections against 
illicit intercourse is the fear of con- 
tracting venereal disease. By regula- 
tion and medical examination this 
would, to a great extent, be done away 
with, and, therefore, tend to increase 

5. Medical examination is inefficient. In 
many cases venereal disease can be 
diagnosed only by the specialist, and 
with the greatest difficult}'. 

6. It is impossible to control all women 
practising prostitution; even in cities 
where regulation is most favorably 
carried out only a small proportion 
of the prostitutes are under control. 

At best, regulation affects only the 
women, while the men are quite as 
virulent spreaders of venereal disease. 

8. It is impracticable to all the in- 
fected prostitutes in public institutions. 

9. Segregation produces centers of crime 
and depreciates the value of property. 

10. Segregation lends to increase the pub- 
licity of prostitution. 

II Faults of administration often cause 
failure in the licensing system. 

3. As prostitution is now illegal, "graft" 

at present is prevalent. The city 
authorities recognize that prostitution 
is necessary, and therefore do not inter- 
fere, but allow the prostitute to pay 
the poHce of her district for protection. 

4. This argument cannot be entirely re- 
futed. Certain extremists, however, 
claim that on this basis our attitude 
should be to favor the spread of venereal 
disease, so as in this way to make illicit 
intercourse more dangerous. 

5. With the aid of the Wassermann reac- 

tion and modern methods of cultures 
and staining of the gonococcus, diag- 
nosis is not difficult — certainly not so 
in cases likely to produce infection. 

6. Regulation is not a means of eradicating 
venereal, Init for every infected 
prostitute that is controlled, a certain 
number of cases of venereal disease are 
prevented. The lower class of prosti- 
tutes are the ones that always come 
under control, and are those in whom 
regulation is most necessary. 

7. Whereas a man has intercourse v.ith 
one woman, a prostitute has inter- 
course with twenty or more men. But 
a small proportion of infected men will 
practise fornication, as they all know 
that the}' are infected. Some women 
are not aware of their condition, 
whereas others will continue their trade 
for financial reasons. 

8. The large number shows the urgency of 
reducing the amount of venereal disease. 
Only in an infectious state need 
be incarcerated. It would seem that 
the new Ehrlich-IIatta specific may 
greatly diminish the time required to 
effect the cure of syphilis. Gonorrhea 
is a curable disease. 

9. Segregation tends to prevent the dis- 
semination of vice, aiifl therefore pro- 
tects the innocent. Districts should 
be well lighted. Segregation is a 
natural result. Every large city has 
its "tenderloin," where property is not, 
as a rule, cheap. 


This is not the case, as witness Hamburg 
and other cities. 

11. a system is inotlicieiilly ad- 
ministered, it does not follow that it is 
without value. 


Arguments For and Against the Official Regulation op Prostitution — (Continued) 

12. Regulation would increase the number 12. Not the case. But rather tends to 

of prostitutes. lessen the dangers of seduction of 

innocent girls. 

13 Medical examination of prostitutes is 13. It is difficult to understand what injury 
an outrage upon the sex and tends to a medical examination can do to the 

degrade the woman. modesty of a class whose trade necessi- 

tates the abandonment of all modesty 
and the habitual exposure of the person 
for hire. Moreover, professional ex- 
aminations for the detection of disease 
are common occurrences of every-day 
life, and are not held to be in the nature 
of an assault, even when made against 
the will of the individual, as in quaran- 
tine inspections or examination of sol- 
diers held in our own and most other 
armies, for the purpose of detecting 
venereal and other diseases (J. R. 

The foregoing summary appears to favor official recognition of 
prostitutes. The crux of the situation is not whether such recognition 
could do good by lessening venereal diseases, but whether such a 
system could be efficiently enforced in the face of so many difficulties. 
It is the author's belief that, in this country at least, it could not 
be enforced for reasons that will be stated further on. 

Harwood^ tells of regulation in a settlement of steel workers the 
force of which was crippled by venereal disease. Medical examination 
and cooperation with the keepers of the brothels produced good results. 
Many similar instances are recorded in military posts and garrisons. 
It has been suggested that brothels be licensed by the municipal au- 
thorities, somewhat in the same manner that saloons are at present 
licensed in this country, the license to be a liigh one. It is claimed that 
this system would in some measure do away with many of the present 
objectionable features of prostitution. The poUce would know the 
location of each brothel, and could easily locate an inmate whenever 
desired. If desired, segregation could readily be enforced. Petty 
robberies and disorder would diminish or disappear, for a proprietor 
would not risk losing a license for which a large sum was paid annually — 
say $1000 — for insignificant gains. There would be fewer houses 
of ill repute, and those that did exist would be better kept. The 
present "graft" of the police would be done away with. The sys- 
tem would soon pay for itself. The "white slave" traffic and the 
harboring of minors would be lessened, if not entirely eliminated. 
The cancellation of the license, if the regulations were not obeyed, 
would always be a weapon to hold over the head of the proprietor. 

' Kean, J. R.: Mihtary Surgeon, March, 1912, p. 251. 
' Harwood: Jour. Amer. Med. Assoc, December 22, 1906. 


The fact that the houses were well managed would tend to drive the 
clandestine prostitute and dive-keeper out of business, and, lastly, — a 
very important point, — the sale of liquor in brothels could be sup- 
pressed entirely. The trade with minors — and there is no doubt that at 
present minors constitute a very definite proportion of the frequenters 
of certain houses of ill repute — would be eliminated. The system 
might easily be co'mbined with medical supervision, but this would 
seem to be superfluous, since it would be to the proprietor's advantage 
to harbor only such inmates as are free from disease. A complete 
set of regulations would have to be drawn up, and it would be made 
compulsory for the keepers of such licensed bi'othels to observe them 
and see that they are enforced. It would be necessary to combine with 
the foregoing sj'stem a vigorous police crusade against all unlicensed 
brothels and street prostitutes. This plan requires the legalization of 
prostitution. Prostitution is now illegal, and therefore the police can- 
not be asked to supervise it. Xo law can be efficiently enforced unless 
it is satisfactory to the majoritj' of the people. It seems almost 
certain that the American people would not tolerate the legalization 
of prostitution. 

.Vt the present day the inmates of many of the more luxurious 
brothels are examined at regular intervals by a physician employed by 
those in charge of the establishments. In Russia, in some of the houses 
of ill fame, a student physician is retained, who not only treats the 
inmates, but examines all the male patrons. 

Excluding the moral aspect, theoretically regulation of prostitution 
should tend greatly to lessen the prevalence of venereal disease, and 
has been proved to do so in many of the smaller communities. With 
the possil)le exception of Germany, practical experience has thus far 
failed to demonstrate the advantages claimed for regulation. Powell^ 
states that in St. Louis regulation did not lessen disease, but did in- 
crease licentiousness. Nevins' states that the system of regulation 
iioininally established in India in 1888 was a failure. 

The strife, as it at present exists, between the abolitionist and the 
regulationist, is a fruitless battle. The animosity, if not intolerance, 
that is often exhibited by the former, and that almost wrecked the 
Brus.sels Congress of 1906, is well known. Arguments as to the ad- 
visability of devising some means for lessening venereal disease may 
easily demonstrate conclusions upon the one side, but sentiment and 
convent ionality are equally powerful in fornuilating contrary con- 

' Powell: Quoted by .J. M. Mabbott, Trans. \ew York Olwt. Soe ., liMm-l'.tll, p. .iss. 
' Nevins: Quoted by J. M. Mablsott, loc. cil. 


Great diversity of opinion exists as to the benefits to be derived 
from tlie attempted reformation of prostitutes. Certainly tfie atti- 
tude that is exhibited by the Cierman government toward these women 
deserves praise. Even hardened prostitutes can scarcely be regarded 
as criminals, and there can be no two opinions as to the younger mem- 
bers of this profession. It is nevertheless a sad fact, admitted by 
most authorities on this subject, that attempts at rescue of prostitutes 
are not attended by marked success. There are in Greater New 
York 24 reformation and rescue homes. The work done by these 
institutions is most praiseworthy, but the percentage of permanent 
reformations that are effected is comparatively small. Unless the 
prostitutes are young or are reached early in their career, success 
rarely follows such efforts. 

After an exhaustive study of the subject of prostitution and a care- 
ful review of the literature, the author is led to the following conclu- 
sions: (1) That efficient regulation of prostitution is possible, and would 
undoubtedly lessen the spread of venereal disease. Unfortunately, 
practical experience has shown that regulation in large cities is attended 
by so many almost insurmountable difficulties that its beneficent 
efTects are almost nugified. Theoretically, regulation should be 
possible and eflScient, but results do not sustain the theory. Excel- 
lent results have followed regulation in small communities, such as 
military posts, etc., but in large cities it is nearly impossible to enforce 
regulation with suflficient stringency to be of any service. (2) 
Owing to the high cost of living and low wages there is, in this coun- 
try, an ever-increasing class of young women, drawn largely from 
the shop-girls and others who are forced to earn their own living, that 
are immoral. These girls are not prostitutes, in the ordinary sense of 
the word, and are not so considered by their associates. They are 
generally included in the class termed clandestine prostitutes, and are 
for the most part girls who are forced to add to their incomes in some 
way. The Chicago Vice Commission, in its recent report, has amply 
proved this point. Peterkin' states that in Seattle the clandestine out- 
number pubhc prostitutes 10 to 1. Kelly- believes that all vice is 
a reflex of social conditions — of poor housing and poor wages. He 
finds that in Baltimore 80 per cent, of the women employees in depart- 
ment stores receive less than a living wage. Regulation cannot reach 
this class. Nevertheless, while it is impossible ever to regulate all 
prostitutes, this should not detract from the good that can be accom- 
plished by the control of some of them. (3) It would be unwise to 

' Peterkin, G. S.: Amer. Jour. Dermat,, August, 1912, p. 407. 

2 Kelly, H. A.: Jour. Amer. Med. Assoc, October 5, 1912, p. 1312. 


attempt official regulation of prostitution in this country, owing chiefly 
to the strong public sentiment that exists against such a procedure. 
(4) At best, regulation of prostitution is of comparatively minor im- 
portance in the cjuestion of the prophylaxis of venereal disease, com- 
pared with educational and other methods, some of which will be de- 
scribed in the following chapter. These offer a far better prospect for 
the ultimate solution of this difficult problem. 


1. Bicrhotf : New York Med. Jour., August 17, 1907, pp. 24 and 31. 

2. HierhofF: New York Med. Jour., March 2.5 and April 1, 1911. 

3. de Fore-st: N. Y. State Jour. Med., October, 1908, p. 516. 

4. Demeritt: .\nier. Jour. Dprraat. and Gen.-Urin. Diseases, 1910, vol. xiv, p. 422. 

5. Ellis: Med. Record, July 11, 1908. 

6. Greene: Cal. State Jour. Med., January, 1910, p. 15. 

7. Harwood: Jour. Amer. Med. Assoc, December 22, 1906. 

8. Hund: Amer. Jour. Dermat. and Gen.-Urin. Diseases, 1909, vol. ,\iii, p. 23. 

9. Kime, R. R.: Atlantic Jour.-Record of Med., April, 1911. 

10. Lecky: History of European Morals. 

11. Newcomb: Cleveland Med. Jour., February, 1911, p. 98. 

12. Social Evil in Chicago, Report of the Vice Commission, 1911. 

13. Tuffier: Jour. Amer. Med. Assoc, October 20, 1906. 

14. Vecki: .\mer. Jour. Dermat. and (!en.-Urin. Diseases, 1910, vol. xiv, p. 213. 
lo. WestmirLster Review, December, 1899, p. 608. 

16. Williams: Lancet, 1906, vol. i, p. 361. 

17. Report of the Committee of Seven, Med. Record, December 21, 1901. 

15. Keifer and Kober: Report of Committee on Control of Venereal Disease by a Mu- 
nicipality, Jour. Amer. Med. Assoc, September 23, 1911. 

Chiefly .\merican and English literature has purposely been referred to in the considera- 
tion of this subject. 



One of the most important points in securing efficient prophylaxis 
against venereal disease lies in effecting sterilization of the source of 
infection. The regulation of prostitution, even if properly enforced, 
controls only the female gonorrheic, the male being free to spread the 
disease, and although the woman is for many reasons the most prolific 
source of infection, the man is an undoubted factor, and must be taken 
into consideration if any satisfactory campaign against ^'enereal dis- 
ease is to be instituted. The necessity, therefore, of completely curing 
all venereal patients cannot be overestimated. A large j^roj^ortion of 
venereal patients are unable to afford the services of a private physi- 
cian, and the dispensary, and especially the hospital ward, acconuno- 
dations open to such patients in this country are entirely inadequate. 
In New York city, in 1910, of 49 general hospitals, only 11 admitted 
venereal patients. Of 10,536 hospital beds, 400 were open to venereal 
patients, and these were not reserved for them exclusively, but were 
used for genito-urinary patients in general. Of these 49 hospitals, 36 
were municipal institutions (Bierhoff^). In 1908, in Boston, only one 
hospital would receive a case of syphihs. In Philadelphia the Phila- 
delphia General Hospital is the only institution that freely admits 
venereal patients. Christian- states that he sent a communication to 
14 hospitals in Pennsylvania, all but one of which received State aid, 
requesting information as to whether or not they admitted ^•enereal 
patients. A negative answer was received in every case. 

In Cook County, 111., there is only one hospital where venereal 
patients can receive free treatment, and there is only one other hospi- 
tal in Chicago where pay venereal disease patients will be received.' 
A similar state of affairs exists all over our country. Increased hos- 
pital facilities for venereal patients constitute a crying need. 

The Commission of the Medical Society of Pennsylvania'' has re- 

' Bicrhoff: New York Med. Jour., August 17, 1907; also ibid., March 25 and April 1, 

2 Christian, H. M.: The Pennsylvania Med. Jour., July, 1912, p. 790. 
' The Social Evil in Chicago, 1911, p. 304. 

* Report of the Med. Soc. of Pa., sixty-first annual meeting, September 25-28, 1911. 


cently recommended that a medical certificate certifying that the 
applicant is free from venereal or other contagious diseases be de- 
manded from every man who contemplates marriage; that one who 
conveys venereal disease should be punished by imprisonment, and 
that provision should be made for securing segregation, so that the 
pubUc maj^ be protected. These recommendations were accepted by the 
Society. The following resolution has recently been passed by the 
New York Obstetrical Society^: "That the time has come to make a 
beginning in the regulation and control of venereal diseases. That the 
first necessity is a place of detention and care for flagrant and especially 
dangerous cases." Fournier, Neisser, Brieux, and all authorities on 
this subject strongly recommend increased hospital facilities for ven- 
ereal patients as a means of prophylaxis. Fournier suggests that not 
only should dispensaries be increased in number, and that each should 
have a number of small consulting-rooms, but that they should be 
open for two hours in the day and for a similar period in the evening. 
This last is an important suggestion, more especially for men, who in 
many cases cannot leave their work during the day for treatment. 

Bernart- found that of a series of 50 male venereal patients, only 
25 were able to leave their work for treatment during the day. The 
genito-urinary dispensary should be designated by a letter or number, 
so as to avoid the objectionable term, diseases of men. A female 
physician is of great assistance in a gynecologic dispensary, for a cer- 
tain proportion of women prefer her to a male practitioner. The 
treatment in dispensaries for both men and women should be modern, 
and combined with facilities for making exact laboratory methods of 
diagnosis. Each patient should be warned of the nature and con- 
tagiousness of his or her disease. In the Teleia dispensaries in Buda- 
pest the patient, if married, is warned of the infectiousness of the dis- 
ease, although care is taken not to incriminate the husband or wife, as 
the case may be. The possibility of extragenital infection is dwelt 
upon, and an effort is made to have the partner in marriage come to the 
dispensary for examination and treatment. Unmarried patients are 
told of the chronic and sometimes latent character of their disease, and 
are advised, in case of intended marriage, to return for a further 
examination. The Teleia dispensaries are successful along these lines, 
and the patients usually act on the suggestions made. 

.\n excellent plan is that suggested by Rathburn,'' who gives each 
venereal |):itient a small pamphlet. He finds that patients nearly 

' Trans. New York Obst. Soc, 1<«)>»-1<.)10. 

' Bernart: Amer. Jour. Derniat., 1908, p. 270. 

' Rathburn: Long Island Med. .Jour., 19()K, p. 24. 


always take these home and read them. These pamphlets explain the 
nature and infectious character of their disease, its contagiousness, and 
dwell upon the necessity of continuing the treatment until a cure is 
effected. Such pamphlets can be printed at a very small cost. Rath- 
burn has separate ones for the use of gonorrheics and syphihtics. 
Those intended for patients suffering from gonorrhea read as follows: 

Rathburn's Pamphlet 

"Gonorrhea, or clap, as it is generally called by the laity, is a disease 
that is caused by a special germ or microorganism; whenever these 
germs are deposited upon a mucous membrane, as, for example, the 
genital organs, gonorrhea results. The disease is usually transmitted 
from one to another by means of sexual intercourse. It is possible to 
contract the infection through contamination from water-closets and 
other sources, if these have previously been infected by some one 
having the disease. 

"It usually manifests itself in from three to ten days after exposure. 
The first symptom is a stinging pain on urination, followed by the dis- 
charge of pus from the urinary canal. Each drop of this pus contains 
millions of bacteria and is highly contagious. Its virulence may be 
estimated from the fact that a small drop, placed in the eye, would 
completely destroy this organ in one or two days. 

"The disease, if properly treated, may be entirely cured in from four 
to six weeks. So-called ' cures ' that claim to take effect in a shorter 
time are frauds. When neglected or improperly treated, the disease 
becomes one of the most dreadful conditions that affect mankind, and one 
of the most difficult to cure. It occasionally results in complete loss of 
sexual power, and sometimes, when neglected too long, becomes abso- 
lutely incurable. 

"Men often believe themselves cured because there is no running or 
discharge, but a close examination on arising in the morning will often 
disclose the presence of a small drop, or if this is absent, the urine, when 
passed into a small glass, will show a cloudiness or a number of small 
shreds or particles (normally, urine, when passed, should be clear). 
These particles often contain large numbers of germs. At this stage the 
disease is just as contagious as when an abundant discharge is present. It 
is by this class of cases, occurring among men who think they are cured, 
but who in reality are not, that the disease is spread abroad, or the newly 
married man may infect his wife. The latter may have but little or 
no trouble at the time, but later on she becomes a chronic invalid, 
securing relief only as the result of a severe surgical operation, occasion- 
ally involving the removal of the entire uterus. Nearlv one-third of 


all the grave operations performed upon women in hospitals are done 
for diseases that had their origin in this cause. If children result from 
the marriage, there is a possibility of their being blind from birth. 
Practically all children blind from birth — and there are thousands of 
such cases — are rendered so as the result of gonorrhea in the parents. 

" Now as to the method of avoiding the disease and its dire results. 
Without doubt the safest and best plan is to avoid illicit intercourse. 
Sexual intercourse I's by )io t7ieans essential to the maintenance of perfect 
health. Many of the healthiest and best developed men are those 
who have never had intercourse until they married. 

"\Mien, however, a man is so unfortunate as to acquire this disease, 
he should at once place himself under the care of a competent physician. 
If this is impossible because of lack of funds or from other causes, he 
should apply to the nearest dispensary, and remain under treatment not 
only until the discharge has ceased, — for the disease is not necessarily 
cured by that time, — but until the physician has pronounced him cured." 


1. Don't attempt to treat yourself! You would not attempt to treat 
yourself for consumption: it is no easier to treat gonorrhea. 

2. Don't be treated by your friend or druggist! No two cases of gonor- 
rhea are exactly alike, and what cured your friend ma}' not cure you. 

.3. Don't allow yourself to be treated by the quacks who advertise in 
the newspapers! These are the worst kind of frauds and never cure 
the disease. They may arrest the discharge temporarily, but, not 
being properly cured, the disease returns in a few weeks or months. 

4. Don't neglect the condition until it becomes chronic! It may take 
months or years of treatment to cure if you do. 

5. // you hare had gonorrhea, don't marry until you hare been cramined 
by a physician and have been told that you are icell. The disease may lurk 
in the system long after you think you are cured. 

(i. Don't fail to wash your hands thoroughly after each urination and 
after each time you touch the diseased jmrts. Failure to do this may 
result in the loss of an eye. 

7. Don't have sexual intercourse until you are cured. Not oiil.v will 
you infect your partner, but you will retard your cure. 

8. Be careful not to infect water-closets or other objects from which may be conveyed to innocent persons. 

The pamphlet just outlined is inteiuUnl for the use of men, and a 
somewhat modified one should be prepared for the use of women, es- 
pecially emphasizing the danger to children from sleeping in the same 


bed with an infected mother. A pamphlet somewhat similar to this 
one was adopted in 1908 by the State Board of Health of Rhode Island 
and by the American Public Health Association, and is also employed 
at the new York hospital in Pennsjdvania. In Iowa a movement has 
recently been instituted to place gonorrhea and syphilis upon the same 
footing with other contagious diseases. 

At the present time Porto Rico and 34 States and territories 
have laws concerning ophthalmia neonatorum. Kerr^ states that the 
State health authorities of Massachusetts, Rhode Island, New Jersey, 
and Vermont are specifically authorized in law to furnish prophy- 
lactic outfits to physicians for use in their practice. Kerr states that 
in France ophthalmia neonatorum is classed as one of the communic- 
able diseases, must be reported, and is subject to disinfection. In 
Italy the regulation for midwives provides that the lids and conjunc- 
tivEe of infants must be washed after birth with a disinfecting solu- 
tion, and that if inflammation develops, a physician must be called 
immediately. In Belgium a physician must be called to attend all 
cases of ophthalmia neonatorum, while midwives, before bathing the 
infant, are required to wash its eyes with sterilized water. In Bavaria 
the midwife is required to carry with her a vial containing silver 
nitrate solution, with directions for use. In Austria a penalty is pro- 
vided for midwives failing to call a doctor in cases of ophthalmia 
neonatorum. Similar regulations are in force in Switzerland. 

' Kerr, J. W.: Ophthalmia Neonatorum, Public Health Bulletin No. 49, October, 1911, 
Washington, Government Printing Office. Connecticut: General Statutes, 1902, Sec. 
2535; district of Columbia: Regulation for the Prevention of Blindness, Sec. 1, 2, and 3; 
Idaho: Revised Codes, 1908, Sec. 1108; Illinois: Chap. 38, Kurd's Revised Statutes, 1909, 
Sec. 510 and 511; Indiana: Acts of 1911, Chap. 129, Sec. 1, 2, 3, 4, and 5; Iowa: Acts of 
1896, Chap. 57, Sec. 1, 2, and 3 (omitted from code of 1897; Sec. 27, Chap. 20, Acts of 1897, 
declares that the code is "the authoritative publication of the existing laws of the State"); 
Kansas: Resolution, State Board of Health; Louisiana: Sanitary Code, 1911, 62 (fi), (b), 
and (c); Maine: Revised St:iiiitrs. HKi:;. ( 'h^ip. 18, Sec. 90; Maryland: Code of 1904, 
article 27, Sec. 231; Massirlius, ii>. i;,.M>,.,i Laws, 1902, Chap. 75, Sec. 49 and 50; also 
Chap. 458, Acts of llilo, Scr, I mihI l'; .iIm. uf 1911, Chap. 643; Micliigan: Compiled 
Laws of 1897, Sec. 447;") and 4l7(i; Miimr.-nia: Uctiuhition. Stale Hi.ard of Health, Sec. 80 
and 81; Missouri: Revisi>il Suitutes, l(ili:i. See. s:;_'l, s:;.'_'. aii^ n:;_':;: Xelirasku- Regula- 
tion, State Board of Health, Rule L'lC New llainpshire: A.ts of I'.lll, Chap. 121, See. 1, 
2, and 3; New Jersey: General Staiuies. |s!i."., p. 1676, Sec. 1, 2, 3, and 4; also Acts of 1911, 
Chap. 96, Sec. 1 and 2; New YfJik; ( miM.lidated Laws, 1909, Chap. 40, Sec. 482; also 
Acts of 1910, Chap. 513, Sec. 1; also lleaith Department; also State Department of Public 
Health Manual, p. 129; North Dakota: Acts of 1911, Chap. 188, Sec. 1, 2, 3, 4, and 5; 
Ohio: General Code, 1910, Sec. 12787; Oregon; Rules and Regulations, State Board of 
Health, 1911, Rules 1 and 3; Pennsylvania: Purden's Digest, thirteenth edition, p. 1886, 
Sec. 78, 79, 80, and 81; also Acts of 1911, p. 931, Sec. 10; Porto Rico: General Order No. 
170, 1889; Sec. 51, 52, .53, 54, 55, 56, and 57 (given force of law by Sec. 8, p. 79; 31 Stats.L); 
Rhode Island: General laws of 1909, Chap. 343, Sec. 25, 26, and 27; South CaroHna: 
Criminal Code, 1902, Sec. 331; TennesMi.; Chap. 10, Acts of 1911, Sec. 1; Texas: Acts of 
1909, Chap. :30, Sec. 10; Utah: Aii>.il lui I , ( 'hap. 61, Sec. 1; also Rules of State Board of 
Health; Vermont: Chap. 220, Acts ci I'.Hd, .>ec. 1 and 2; Wisconsin: Annotated Statutes, 
1898, Sec. 1409a (added by Cliai). 59, Acts of 1909), 1409a, 1, 2, 3, and 4. Reference to 
decision rendered against individuals for infringements or lack of prophylactic measures 
.against ophthalmia neoiiatcinuu inav be found under Cowley vs. People, 83 N. Y. 464, 
and Peojjle vs. Pierson, 176 N. Y., 201. 


Earh' in 1911 the London Council issued an order making ophthal- 
mia neonatorum a reportable disease. Thus, as in cases of specific 
fevers, immediately on diagnosis a case must be reported to the health 
officer. The object is that more effectual means may be taken for its 
prevention and treatment. Several smaller towns have also adopted 
this measure. This is characteristic of the attitude taken by most 
English-speaking races toward venereal disease. If we recognize the 
infectious nature of ophthalmia neonatorum, how much more neces- 
sary is it that a similar recognition should be given to gonorrhea 
in adult patients who are up and about and, for many other reasons, 
are more likely to spread the disease. 

The New York Board of Health now requires the registration of 
venereal disease in persons treated in pubhc institutions, and requests 
all physicians to furnish similar information concerning private pa- 
tients under their care, permitting the names and addresses, however, 
to be withheld. Such reports are considered confidential. The De- 
partment of Public Health also provides facilities for free bacterio- 
logic and serum tests, for venereal diseases, when data required for 
the registration of the case are furnished.' California and Vermont 
require registration of gonorrhea, which is carried out by number and 
not by name. This is a step in the right direction. Individual rights 
should not be allowed to take precedence over public welfare. 

Nearly all the increase in the eflficiency of public hygiene has been 
attained by educational methods. No better way of directing the 
attention of the laitj' to the ravages of venereal disease could be 
adopted than by the formulation of a universal law requiring the regis- 
tration of this class of maladies. 

Professor Coplin, ex-director of Public Health of Pliiladelphia, is 
of the opinion that all male and female venereal patients that are 
likely to spread their infection should be forcibly controlled. In 
Massachusetts there is a statute (Chapter 75, Section 48) to the effect 
that an inmate of a public charitable or penal institution who has 
syphilis in a contagious form shall, at the expiration of his or her 
term, subject to the opinion of the physician in charge, be detained 
until such time as, in the physician's opinion, the said person is no 
longer contagious. There is no reference to gonorrhea. Like Eng- 
land, the United States has no law against infecting others with 
venereal disease, as shown by the recent decision of the Sujjreme Court 
of Mississippi. - 

' Ptnn, .Med. Jour., .\pril, 1912, p. 581 

' AuHtin vg. State (Miss.), 56 So. R. 345; also Jour. Aincr. Mcil. A.-isor., Ai)ril i:5, 1912, 
p. 1U2. 


An unusual case in point was that reported by Dr. Isadore Dyer, of 
New Orleans, before the Brussels Conference on the Prevention of 
Venereal Diseases in 1899— a patient with primary syphilis who 
refused even charitable treatment, and carried a book wherein she 
kept a record of the number of men she had inoculated. When she 
was first seen she declared that the number had reached 219, and that 
she would not be treated until she had revenge upon 500 men. 

The system, as already described in the chapter on Prostitution, of 
making venereal disease reportable, as adopted by Norway, has been, 
in that country, extremely successful. In the large standing army 
of Germany there are frequent medical examinations, during which 
especial attention is directed toward venereal disease. If such cUsease 
is detected, the patient is sent to a hospital for treatment and deten- 
tion. Too much stress cannot be placed upon the necessity of entirely 
curing gonorrhea, as the increase of the affection is due directly to the 
number of uncured cases. Physicians are sometimes to blame for allow- 
ing patients to discontinue treatment before they are entirely cured, and 
for not making thorough tests to ascertain this beyond question. 
It is, however, a fact that there are not a few general practitioners 
who, because of lack of knowledge or facilities, are unable to make 
such tests, and this is especially the case in dealing with female gon- 
orrheics. It must always be remembered that chronic gonorrhea is 
the most potent factor in the spread of this disease. At this stage tlie 
symptoms are often mild, and the diagnosis in either the male or the 
female is difficult. The most painstaking efTort should be made 
entirely to eradicate the disease. In some medical schools venereal 
diseases are not thoroughly taught, and, as a result, practitioners are 
sent out who are unalsle properly to treat such diseases, and who do 
not realize the importance of thorough treatment. State boards should 
emphasize the importance of venereal diseases. Patients suffering 
from venereal disease are notoriously difficult to control, and this is 
particularly true of dispensary patients. This doubtless accounts for 
many uncured cases. Davis^ records that the number of visits to a 
clinic by 450 gonorrhea patients, nearly all of whom were in the acute 
stage, was as follows: One or two visits, 285, or 63.4 per cent.; three 
to five visits, 80, or 17.8 per cent. ; six or more visits, 85, or 18.8 per 
cent. Even supposing that the majority of these patients went else- 
where for treatment, it is obvious that, in a large proportion, the course 
of the disease must have been prolonged. The quacks and patent 
medicine venders are also prolific sources of gleet, and should be sup- 
pressed for this, if for no other, reason. 

' Davis, M. E.: Jour. Anier. Med. Assoc, Xoveinhpr 9, 1912, p. 16S9. 


Marriage of Gonorrheics. — The frequency with which women are 
infected by liusbands who beUeve themselves cured is well known. 
These women, it has been estimated, constitute one-third of all the 
married women suffering from gonorrhea seen in private practice. 
Occasionally the position is reversed, and the husband is the innocent 
sufferer, but this is by comparisoii rare. Morrow' estimates that there 
are 250,000 married women in the United States suffering from gon- 
orrhea, a fact that evidences the necessity for securing prophylaxis 
in this direction. This is an extremely conservative estimate. The 
frequencj^ of pelvic inflammatory disease and sterility among married 
women and their etiologic relationship to gonorrhea are well recog- 
nized. Physicians are in many cases to blame for not explaining more 
thoroughh', at the time of the acute attack, the nature, chronicity, 
and dangers of the disease in case of future marriage of their patients. 
Patients who do not continue ti-eatment until cured are also to be 
censured. To safeguard the innocent, it has been suggested that each 
partner should be required to present a medical certificate stating that 
he or she is free from all contagious disease at the time the marriage 
certificate is issued. As the female is but comparatively rarely the 
source of infection at such times, and because of the oiivious difficulties 
and unpleasantness attending an examination under such circum- 
stances, it would seem that a certificate from the female should not be 
demanded. With the male, however, the condition is quite different. 
The proportion of men who have suffered from gonorrhea prior to 
marriage is very large, and the necessary examinations are much less 
embarrassing. If. as has been suggested, venereal diseases were made 
notifiable, this in itself would greatly facilitate such prophylaxis re- 
garding those who had at any time suffered from gonorrhea. Here, 
too, a law making it a punishable offense to communicate a venereal 
disease would be of especial benefit. In 1905 the State of Indiana 
passed a law to the effect that no person afflicted with atransmissil)le 
disease shall be privileged to marry. The State lioard of Health is 
given discretionary powers in the execution ol this statute. They 
propound questions to every applicant for a marriage license. The 
answers must be sworn to, and penalties prescribed for concealment of 
venereal disease under such circumstances. Similar laws are in force 
in North Dakota, Michigan, and in some other of our western States, 
as well as in Holland and Sjiain. The Ohio State Medical Association, 
at its meeting in Cleveland on May IS, 1911, urged the passage of 
State Bill No. 'M, which provides for the physical examination of all 

' Morrow, 1'. A.: Social Disruscs aii.l M:irri:in.-, I'.KM. 


men applying for a marriage license.' Similar legislative measures are 
now being considered in Utah.= Such laws, if made general, would to 
a certain extent be evaded, but their moral effect, by calling attention 
to the necessity of freedom from venereal disease in those about to 
marry, would be extremely beneficial. 

Ethical Duty of Physician Toward Gonorrheics. — Professional se- 
crecy is one of the oldest and most praiseworthy assets of the medi- 
cal profession, and the necessity for it has been recognized since the 
time of Hippocrates. In the majority of our States, as also in most 
foreign countries, laws are in force definitely to cover this point. 
Article 834, of the Code of Civil Procedure of New York, reads as 
follows: "A person duly authorized to practice physic or surgery shall 
not be allowed to disclose any information acquired in attending a 
patient in a professional capacity, and which was necessary to enable 
him to act in that capacity." This law, however, is not enforced, for 
it does not carry with it a penal responsibiUty for its violation. The 
French law is more severe, and prescribes a punishment of from one to 
six months in prison and a fine of from 100 to 500 francs. In individual 
cases exceptions have been taken to such laws both in this country 
and abroad. Much has been written upon this subject, and there is no 
doubt that a physician should, under such conditions, be influenced 
largely by the circumstances surrounding the individual case. The 
cases that are usually the most difficult of solution are those in which a 
man, known to the phj^sician to be the victim of an infectious gonorrhea, 
purposes to marry a healthy woman; in such cases tact, discretion, and 
firmness will in most instances suffice. In a case seen by Piogey the 
intended bridegroom insisted on the marriage taking place, declaring 
that the ceremony was absolutely necessary because of financial rea- 
sons. He was prevented from accomplishing his crime only by Piogey 
threatening pubhc insult and a subsequent duel. Such chivalrous 
methods are, of course, hardly necessary in this country, and in more 
than one instance a jury has upheld a physician who has interfered 
under like conditions. The general trend of both the professional and 
the lay opinion seems, very rightly, to be toward a relaxation of strict 
professional secrecy under such circumstances. 

Personal Prophylaxis. — This includes such measures as may be 
adopted by the individual, male or female, either before or after coitus, 
to prevent venereal infection. This subject, like that of prostitution, 
undoubtedly has a moral aspect, and the question whether we should 
recommend means by which infection may be more or less combated. 

» New York Med. Record, May 27, 1911. 

^ Bogart, G. H.: Amcr. .lour. Dermat., January, 1912, p. 23. 


is not unassailable. '\,Miatever harm might be wrought by the dis- 
semination of such knowledge among the laity, there can be no two 
opinions as to the benefit to be derived from such treatment in our 
soldiers in the efficiency and defensive strength of our army and navy. 
Perhaps the simplest means of securing personal prophylaxis is by 
urinating and washing or douching the genitaUa immediately after a 
suspicious intercourse. Urination and, at the same time, pinching to- 
gether the lips of the meatus so as to insure thorough washing out of 
the anterior urethra, is a common practice among men. This simple 
procedure is often effective, and the failure to adopt it no doubt ac- 
counts, to a great extent, for the frequency with which intoxicated indi- 
viduals, when exposed, contract gonorrhea. Moller' states that 67.7 per 
cent, of 661 venereal patients contracted their disease while intoxicated. 

Gonococci develop most favorably on a medium that is nearly 
neutral. The urine is usually strongly acid, as is also the urethra, 
but as a result of sexual excitement considerable mucus that is alka- 
line in nature is thrown out, thus rendering the canal receptive to in- 
fection. Hence infection is favored by all conditions that stimulate 
the secretion of mucus. These include prolonged sexual excitation 
and local congestion, protracted and repeated intercourse, and all 
factors that retard the orgasm, such as intoxication, etc. .Alco- 
holic excesses also favor infection in other ways ; under such circum- 
stances withdrawal is likely to be delayed, and, too, the urine is more 
irritating than normal. It is well known that irritation of the mucosa 
predisposes to infection. The semen is alkaline, and hence tends to 
produce a reaction in the urethra favorable for the growth of the gono- 
cocci. Probably the next most well-known prophj'lactic agent is the 
condom. This is an almost certain means of prevention of contami- 
nation from one partner to the other, provided the condom has not 
been previously infected and is not ruptured. 

The histoiy of the condom is somewhat in doubt. Pfister- States 
that he has found records that indicate the em])loyment of a sort of penis 
sheath, or condom, by the ancient Egyptians, some two thousand years 
B. c. The invention of this article is, however, generally credited to 
John Cundum, an Englishman, some authorities claiming that he was 
a physician in the time of Cromwell; others describe him as a colonel 
in the Guards,' and as living during the reign of Charles II. However 
that may be, the condom attained almost inunediate i)opularitj', a 

' Moller, M.: Zeitschr. f. Bekampf. d. Gcschlechtskrankh., Leipzig, vol. v, puit 7. 
'Pfister, E.: Zeit. f. Uroloeie, Trans. Uerman Uroiogical Coiigrcs-s, Supplement No. 3, 

' A Classical Dictionary of the Vulgar Tongue, 178.5. 


fact not to be wondered at when the prevalence of venereal diseases 
in England at this period is considered. As a result of the unpleasant 
notoriety which his invention achieved, the originator was compelled 
to change his name. The first of these articles was made from the 
cecum of a lamb, by stripping out the mucous coat and rubbing the 
skin with bran and almond oil until it became pliable.^ The fame of 
these articles soon spread over the civilized world, and we find them 
the subject of the well-known witticism attributed to a lady of the 
French court.- 

When the gonococcus is deposited on the mucous membrane of the 
genital tract, it has been found that some hours must elapse before the 
microorganism gains access to the underlying tissue. During this 
period the organisms may be washed off with comparative ease, and 
if it were not that they often entered the openings of small ducts or 
mucous glands, urination or simple washing would be even more 
effective than it is. The gonococcus is quite easily destroyed by anti- 
septics, especially the silver salts, and it is upon these two facts that 
the prophylactic treatment now so generally adopted in the navy is 

Owing to the extreme prevalence of venereal diseases in the army 
and the navy, the medical officers of both departments have been 
forced to adopt measures tending to check the ravages of these dis- 
eases among the troops. Effective personal prophylaxis can be more 
thoroughly instituted in the navy than in the army. In the former the 
following scheme was attempted : When the men returned after leave 
of absence (shore leave), they were asked if they had been exposed to 
infection, and if they would care to take prophylactic treatment. 
This treatment was found to be so successful, and the proportion of 
men who developed venereal disease after such prophylaxis was so 
small that the system was finally, at least on most ships, made com- 
pulsory. On the U.S.S. Ranger the methods of carrying out the 
prophylactic measures are explained by the following rules: 

1. All men, immediately upon return from shore, shall at once 
report to sick bay. 

2. If they have been exposed to venereal infection, they will at 
once take treatment. 

3. If they report themselves as not having been exposed to such 
infection, a record is kept, and should such a man subsequently de- 
velop venereal disease, he will be reported as having disobeyed orders. 

'A matron named Phillips, at Half Moon Street, in theStnni.l, made a fort imp from the 
manufacture of those little articles. She retired for a time, and li;i\ iiil; s.|uandered her 
fortune, agam took up their manufacture, which proved so successful thai she was again 
enabled to retire in 1776. 

- "A cuirass against pleasure and a cobweb against danger." 


4. The sick bay will be open for treatment from 7 to 9.30 a. m. 
Men returning from liberty at unusual hours or whose duties prevent 
them from reporting at the time may receive treatment at any time. 

The following instructions were posted in the sick bay : 

1. Before coming to sick bay m-inate and wash well with water. 

2. In the sick bay wash well with the solution (bichlorid 1 : 2000). 

3. Use half a syringeful of the injection, and retain it in the canal 
for three minutes. (The solution consists of 3 per cent, protargol 
and 15 per cent, glycerin. The glycerin causes the protargol to ad- 
here to the mucous membrane. About 1 c.c. is injected, so as to reach 
the first inch of the urethra only.) 

■4. Rub the ointment (30 per cent, calomel) well into the whole 
penis, and leave it on for two hours. 

The results of this treatment were as follows: Number of liberties, 
39. Number of men on Uberty, 949. Number of men exposed, 256. 
Number of men not exposed, 693. Result, no venereal disease. 

This includes liberties in 10 different ports, many of which were 
well known to be rife with venereal disease. 

A less elaborate but efficient form of chemical i)rophylaxis was 
recommended b\' Hausmann' in 1885. This author instilled a few 
drops of a 2 per cent, solution of silver nitrate into the urethra after 
coitus. This method was later indorsed by Ulmann,-' Blokusewski,' 
Porosz,' Neisser,' and P'rank.*' The latter devised a portable dropper 
to be used for this purpose. 

In 1899 P'rank' performed an interesting experiment, tending to 
show the efficacy of the prophylactic treatment. The urethras of 6 
men were inoculated with gonococci and 3 with 3 to 5 drops of a 20 
per cent, protargol solution. These 3 escaped, while those not treated 
developed a specific urethritis. 

The results obtained on the U.S.S. Ranger as regards prophylaxis 
against venereal diseases are merely confirmatory of those obtained on 
the U.8..S. Concord, on which shij), of 28 1 known exposures followed 
by the adoption of prophylactic measures, there resulted only two 
cases of venereal disease, both of which had- exceeded their time al- 
lowance on shore, and, as a result, treatment had been delayed. The 
connnanding officer of the Concord states that during the first five 
months in which these i)roi)hyIactic measures were in force tiicre was 

' lliiiisin:inn: DciilsiOi. iiiimI. Wocli.. ISS.j, No. 25. 

2 Ulmann: Wicii. iiic.l. HiJitlcr, ()cl(il)rr 2H, 1897. 

' Bloku.sowski : Dcut.scli. mod. Wocli., 1,H9.5. 

' Porosz: Monuts. f. Urol., vol. ix, No. 2, p. 09. 

' Neisser: Deutsch. Me<lieinal-Ztg., 190.5, No. (i9. 

' Frank: Wien. mod. AVoeli., 19()1, No. S. 

' Frank: Allg. nied. CVnl.-Zeitung, 1899, No. .5. 


not a single case of either gonorrhea or syphilis contracted by the crew. 
Henry' states that on the U.S.S. Rainbow, of 529 admitted exposures, 
there were four cases of gonorrhea; one of these failed to receive treat- 
ment, and two others were treated more than twelve hours after ex- 
posure; if these cases are excluded, there remains a percentage of 
0.189. On board the Charleston, in the Philippines and in China, 
3828 individual liberties were granted, of which number 437 failed to 
report, and of these, 32 developed venereal disease; 1396 admitted 
exposures were treated; of these, only one developed a disease. The 
Culgo, at Colombo, Ceylon, had 25 exposures, which were followed by 
prophylactic measures; no venereal disease resulted. On board the 
Baltimore, on the Asiatic station, visiting Sydney, Melbourne, and 
Auckland for one month each, with prophylaxis there was "practically 
no venereal disease," whereas the British ships, in the same environ- 
ment, had over 25 per cent, of their crew infected. On the Baltimore, 
at Marseilles, the exposures were estimated at 2280; of these, 13 de- 
veloped gonorrhea, only two of these receiving treatment. On this 
ship the list of men on liberty was sent to sick bay, and on their return 
they reported at sick bay and were checked off. If a man was under 
the influence of liquor, he was sent to sick bay in charge of a messenger. 
On the Tacome educational measures were attempted, but failed la- 
mentably, and forced prophylaxis was instituted. Of 756 men exposed 
and treated by prophylactic measures, none developed venereal dis- 
ease. On the Virginian, the following instructive results were ob- 
tained. For oije quarter (three months) no prophjdaxis was attempted 
and 30 cases of venereal disease developed. Optional prophylactic 
measures were instituted for two quarters (of three months each) , and 
resulted in the development of 23 cases of venereal disease for the first 
quarter and 41 cases for the second quarter. During the last quarter 
compulsory prophylaxis was in force, and there were 13 cases of ven- 
ereal disease. During the latter period 1178 men admitted exposure 
and were given treatment. Of these, 5 developed venereal disease. 
The remaining 8 had denied exposure and had not received treatment. 
Ledbetter- reports from Cavite, Philippine Islands, a station in which 
venereal diseases are prevalent, that prophylactic measures have re- 
duced these diseases markedly. Previous to their introduction the 
percentage of venereal diseases of all classes among the men averaged 
from 25 per cent, to 30 per cent, annually, and at times even higher. 
The percentage of gonorrhea has been reduced to 8 per cent, annually, 
and this includes many patients who did not receive treatment. Rat- 

' Henry, R. B.: Assoc. Military Surgeons U. S., Twentieth Annual Meeting, September 
26-29, 1911. 

= Ledbetter: Jour. Amer. Med. Assoc, April 15, 1911, p. 1098. 



ing on a similar basis, chancroids were reduced from 5 per cent, to 2 
per cent., and sypliilis from about 20 cases annually to one case in 

At the naval station in New Orleans, the voluntary plan of prophy- 
laxis proved ineffective, and compulsorj^ methods were adopted. Of 
500 men treated, no venereal diseases resulted. On the Salem, 5300 
liberties were granted, and 6 cases of venereal disease resulted. Two 
of these delayed treatment and 3 did not receive treatment at all. 
On the Georgia, 7494 liberties were granted and 5500 treatments insti- 
tuted; 33 cases of venereal disease resulted, and 10 of these followed 
delayed treatment. On the Rhode Island, on the trip home with the 
battleship fleet from IManila, all men returning from liberty were given 
prophylactic treatment, with excellent results. 

Henry' has employed calomel, 50 grams, liquid petrolatum, SOc.c, 
and lanolin, 70 grams, as a prophjdactic on 529 men who admitted ex- 
posures; 0.189 per cent, developed infection thi-ough failure of the 
treatment. This wTiter further states that of a crew of nearly 200, 
there was not a single case of gonorrhea at the time of writing, a con- 
dition unknown prior to the introduction of prophylactic measures. 

In the Atlantic fleet the voluntarj' system is still in operation on 
many ships. During June and July there were 53G5 acknowledged ex- 
posures and treatments among a total of about 121,000 liberties. Of 
429 cases of venereal disease, only 105 followed treatment, or a little 
less than 2 per cent, of known exposures. Coml)ined reports from the 
Asiatic Station covering 1909, with 70,954 liberties and 21,100 ad- 
mitted exposures, show 599 cases of venereal di.sease, of which 176, 
or 0.83 per cent., received prophylactic treatment. The prophylactic 
report of February, 1910, including the delaj'ed Januarj' report from 
the \'illalobos, showed 1714 admitted exposures among 9408 liberties. 
Among the entire crew there were 57 cases of venereal disease. The 
prol)al)l(' cause given is as follows: 

Failed to rejiort . . . 
Denied exposure . . 
Overwt;iyin« liberty 
ExieiiiliMl liberty. . 
Treated early. . . . . 
Treated late 
















Based un 
Total Cases 


Failures of treatment, based on number reporting and treated on time: Number of 
cases, 10; percentage, 0.04; number of cases of gonorrhea, 4; percentage, 0.20. 

' Henry, R. B.: Military Surgeon, May, 1912, p. 590. 


The fleet surgeon states that many of these infections occurred in 
men in whom treatment was delayed. He adds that "There is no 
reason to think that a sense of security engendered by the scheme 
(prophylaxis) has caused any increased indulgence." Gates sum- 
marizes resiilts as follows: Of 8516 known exposures, plus an unknown 
number of exposures from nearly 20,000 additional liberties, 57 cases 
developed after treatment, whereas 166 cases appeared among the un- 
treated. Of the total number of cases of venereal disease, less than 
20 per cent, developed among those who had received prophylactic 
treatment. The treatment on board ships varies but little, and con- 
sists of washing with soap and water and urinating before reporting at 
sick bay. In sick bay the following procedure is adopted : Wash in 
soap and water; then in bichlorid 1 : 1000 or 1 : 2000 for five min- 
utes. Inject from 1 to 5 c.c. of protargol, 2 per cent, to 3 per cent.; 
or argyrol, 5 per cent, to 10 per cent., and retain the same in the ure- 
thra for from three to ten minutes by the clock. After drjdng, apply 
Metchnikoff's calomel ointment (33 per cent, to 50 per cent, calomel, 
made with lanolin or petroleum or mixtures of these). 

Maus' recommends an ointment containing 30 per cent, calomel and 
3 per cent, phenol in lanolin. This maj' be put up in collapsible tubes, 
which are convenient and cheap. The ointment is rubbed thoroughly 
over the entire penis and adjacent parts, and allowed to remain for 
two or more hours. In some cases, if the men are to go on duty at 
once, the ointment is covered with a light dressing. The men are in- 
structed not to urinate for a couple of hours after receiving treatment. 
The author's experience has been confirmed by that of Ledbetter,^ who 
prefers argyrol to protargol for the urethral injection, since the former 
is less irritating and more efficient. It may be employed as a 10 per 
cent, to 25 per cent, solution. The addition of a little glycerin is 
beneficial, as it causes the mixture to adhere to the urethral mucosa. 
In some cases 2 per cent, protargol solution, if retained in the urethra 
for five minutes, causes pain and discomfort for some hours after the 
treatment. The consensus of opinion among the medical officers of 
the navy is that if this treatment is thoroughly administered within 
eight hours of exposure, protection is almost certain; if within twenty- 
four hours, it is of great value, and should be employed even up to 
forty-eight hours; later than this, however, it is of little use. In the 
navy the treatment is given not by the surgeon, but by hospital at- 
taches and enlisted men of the naval corps. This is due to the fact 
that returning liberty parties on large ships sometimes number 250 

> Maus, L. M.: Quoted by J. M. Phalen, The Post- Graduate, AprU, 1912, p. 225. 
^Ledbetter: Jour. Amer. Med. Assoc, April 15, 1911, p. 109S. 


men. Compulsory measures are not adopted universally in the navy, 
but are subject to the approval of the commanding officer. In addi- 
tion to the medical prophylactic treatment, educational methods are 
in force on many ships, the men being instructed regarding the fre- 
quency and dangers of venereal disease during the first-aid instruction. 
In the German navy prophylactic packages are on sale at a nominal 
price. Failure to use the treatment is regarded as a military offense. 
The packages are small, and contain practically the same articles used 
in the United States navy. Prophylactic measures are also in force in 
the Japanese and French navies. Mummery^ advocates their employ- 
ment in the British navy, and believes that if such measures were 
adopted, venereal disease would be reduced 75 per cent. 

In the army the conditions attending garrison life are not so favor- 
able for the enforcement of personal venereal prophylaxis as in the 
navy, and this doubtless accounts for the fact that such measures have 
not been so widely adopted. Nevertheless, these have, to a certain 
extent, been attempted, and where introduced, have produced good 
results. Huff= recommends that a package be prepared whose con- 
tents are similar in general character to those used in the navy; that 
these be distributed gratuitously by the army medical corps, and that 
they be placed on sale at post exchanges. A similar, but less effective, 
prophylactic, known as the "K" package, is now in use at some posts! 
The "K" package contains a dram vial of a 20 per cent, protargol 
solution in glycerin, or a 10 per cent, aciueous solution of argvrol, and 
a medicine-dropper. Accompanying the kit is a pamphlet giving 
dn-ections for use. Raymond^ reports that of 576 men to whom "K" 
packages were issued, only three cases of gonorrhea resulted. All the 
infected men, however, used the solution improperly (i. e., one or two 
days after exposure). This method of prophylaxis has been of great 
service m some stations in the Philippines, where venereal diseases 
are so rife. Wilson^ reports that at Camp Stotsenburg, Philippine 
Islands, enforced prophylaxis has been adopted. Every man who is 
exposed is required to take the treatment. If he fails to do so, he is 
court-martialed and punished. The treatment is somewhat similar 
to that employed in the navy, and consists in urination, washing with 
soap and water, followed by the injection of a 10 per cent, solution of 
argyrol, which is held in the urethra for five minutes. As a last step, 
30 per cent, calomel ointment is ai^plicd. Wilson believes that by this 
method 00 per cent, of venereal may be prevented. He gives 
the following reasons for preferring this method to the distribution 

J Mummery: Brit. Med. Jour., August 15, I'JOS, p. .304. 

• HiifT: Military .Surgeon, 1909, p. 7.>t. » Uaymonil: Military .Surgeon, 1909, p. 733. 
WiLsoti: .Military Surgeon, February, 1911, p. 102. 


of the prophylactic package : (1) The patient receives treatment under 
the supervision of a man who understands the method. (2) The pa- 
tient is sober and treatment is thoroughly and properly administered. 
(3) Many men are not sober at the time of exposure, and either use the 
package treatment improperly or throw the package away without 
using it. (4) This method is more economic, as, with proper man- 
agement, no waste should occur. (5) A full record can be kept, and 
as a result accurate statistics can be obtained. The disadvantage is 
that more time must elapse before treatment is applied. The army 
method is, for many reasons, less effective than the measures in force 
in the navy, and the "K" package further lacks the antisyphilitic 
and bactericidal properties possessed by the Metchnikoff ointment. 

Feistmantel' relates an interesting prophylactic experiment: 640 
soldiers were divided into three groups: one group received no in- 
struction regarding prophylaxis, and approximately 5.8 per cent, were 
infected. Another group were simply instructed to urinate and wash 
the genitalia with soap and water after coitus; about 4 per cent, of 
these were infected. The third group were given regular prophylactic 
treatment, and about 2 per cent, were infected. None of the men who 
received prophylactic treatment within three hours of coitus were 
infected. Zieler- emphasized the importance of personal prophylaxis, 
and gives minute du-ections how the treatment should be carried out. 
He also urges that phj^sicians should constantly inculcate the necessity 
for thorough daily cleansing of the external genitalia in both sexes, 
even in children. The multiplicity of secreting glands and the putre- 
faction of the secretions are likely to induce irritation and minute 
lesions which open portals to infection of all kinds. Guiard' recom- 
mends thorough washing out of the entu-e anterior urethra with a 
solution of potassium permanganate as a prophylactic against gon- 
orrhea. Apart from the actual prophylactic properties of both the 
navy and the army methods, these are of value simply by calling atten- 
tion to the prevalence of venereal disease. Phalen,'* in referring to the 
situation in the army, states that the voluntary use of the "K" package 
has accomphshed but little, and that the problem, as it now exists, is 
rather administrative than professional, and depends upon getting the 
exposed individual and the prophylactic remedy together. 

Personal prophylactic measures are in force in the Japanese and 
French armies. The German forces, while abroad, are usually sub- 

' Feistmantel: Wien. med. Woch., 1905, Nos. 13 to 17. 

' Zieler, K.: Deut. med. Woch., Berlin, February 22, 1912, vol. xxx\-iii. No. S, p. 345. 
' Guiard, F. P: Jour, de med. de Paris, 1911, vol. xxiii, p. 175; also Rev. prat, d, 
d. org. gen.-urin., Paris, 1911-12, vol. viii, p. 46. 

« Phalen, J. M.: The Post-Graduate, April, 1912, pp. 255-261. 



jected to compulsory prophylactic treatment. Tandler^ states that 
prophylactic measures — injections of 10 per cent, to 20 per cent, of 
protargol — were employed 1560 times in an arm}' detachment of 170 
men, and resulted in a 50 per cent, reduction of venereal disease. In 
the Austro-Hungarian army the experiment Avas made of issuing tab- 
lets of 5 per cent, formalin soap to men about to go on leave of absence. 
It has been suggested that small packages, with directions for use and 
containing such articles as are in vogue in the navy, be placed on sale 
at drug-stores for general use. IVIoral arguments may be adduced 
against such a procedure, but are hardly to be considered as repre- 
hensible as the present ^"ide sale of condoms. These last are, of course, 
purchased with malice aforethought, whereas medical prophjdaxis 
offers a means of preventing an infection in one who has perhaps not 
expected to yield to temptation. Moral arguments against the use of 
medical prophj-laxis can be based onh' upon the supposition that 
venereal disease is the punishment for transgression — an obsolete and 
Puritanical view that is detrimental to any cause, and that, carried 
further, would intimate that no attempts should be made to cure 
venereal patients. If the prophjdactic properties of such packages 
were generally known, their sale would go far toward reducing the 
prevalence of venereal disease among men, and, therefore, among 
women. It seems to have been well proved that this type of prophy- 
laxis can be used with gi-eat advantage by men. It is most efficient 
against gonorrhea and syphilis. On account of the short incubation 
period of chancroid, this form of prophylaxis is less satisfactory when 
dealing with this disease. For anatomic reasons, a prophylaxis such 
as the foregoing is of less .service in the female. Nevertheless, a some- 
what modified form could be applied in many cases, and might, with 
advantage, be combined with other hygienic methods, such as douch- 
ing, etc., now ad\-ise(l for prostitutes in those countries where regula- 
tion is in force. 

In attempting pr()i)hylaxis of a disease as prevalent as gonorrhea, 
and one hedged about with so many difficulties, moral, civic, and i)er- 
sonal, no one .system can be effectual. The two important points to 
be desired are the protection of the uninfected and the cure of the 
di.sea.sed. We should not be hampered by moral doubts and plati- 
tudes, but should endeavor to utilize every known source to check this 
dreaded lesion. It is only by i)utting forth our strongest efforts that 
any hope of ultimate success can be harbf)red. We should realize that 
there is no one ideal projihylactic against gonorrhea, and that different 
methods are re(|uired to reach different i)eopl(>. Fear is undoubtedly 

'TiiiKllcr: DcT Mililiinuzl, XovciiiImt ir,, lOO.j. 


one of the most efficient. Educational methods will not control the 
criminal class, among whom venereal disease is frequent. It is true 
that educational measures may protect the next generation, but 
they will not prevent those now infected from disseminating their dis- 
ease. No methods should be branded as inefficient unless they have 
been definitely proved to be so. Too much should not be expected in a 
short time, as, owing to the character of venereal disease, and of gon- 
orrhea in particular, httle can be hoped for except bj' a prolonged 
effort. Germany has, during the last few years, awakened to the 
necessity of action in this direction, and the scientific world can study 
with advantage the results of her numerous and efficient systems. 
It is impossible, however, to compare Germany with the United States. 
The character of the people, their surroundings, their educational 
methods, and the moral teachings there inculcated are all radically 
different from those existing in this country. Prophylaxis is, at best, 
largely a matter of money, and the necessary means of raising funds to 
carry on such a campaign lies largely with the charitable institutions, 
with individuals, and with the municipal authorities. 


Diehl: United States Naval Med. Bull., 1910, p. 325. 
Eytinge: Military Surgeon, 1909, p. 170. 
Keys: New York Med. Jour., June 29, 1907, p. 1201. 
Oakley: Cleveland Med. Jour., February, 1911. 
Spear: United States Naval Med. Bull., 1910, p. 146. 
Zalesky: United States Naval Med. Bull., 1910, p. 28. 
Amer. Jour. Public Health, 1908, pp. 65, 70. 


The examination of patients for the i)urpose of detecting the pres- 
ence of gonorrhea may be divided into four distinct stages: History 
taking; inspection of the suspected region; palpation; and bacteriologic 

Anamnesis. — The case history should include the age of the patient; 
general previous hist or}'; menstrual history; marital history, which 
should include data regarding pregnancies, miscarriages, abortions, or 
sterilit}' (relative or absolute); the existence of leukorrhea, and anj^ 
subjective symptoms from which the patient may be suffering. Es- 
pecial attention should be directed to the menstrual history, inquiries 
being made concerning changes in the character of the flow and the 
presence of dj^smenorrhea. The question of conception is also an 
important one in this connection. Gonorrhea frequently results in 
sterility; occasionally', however, one or more children will be born, but 
an attack of sepsis followed by steriUty is very suggestive of a Neisser- 
ian infection. Careful inquiry should be made regarding the occur- 
rence of ophthalmia in the children, as its presence is an almost certain 
indication of gonorrhea in the mother. Leukorrhea is also an impor- 
tant symptom. An increase in the amount, and particularly a change 
from the ordinary whitish discharge to a thick yellowish or purulent 
flow, is a manifestation not to be overlooked, especially if this change in 
the character of the flow has followed marriage or a suspicious inter- 
course. Iiujuiries should also be instituted concerning the existence 
of vesical irrital)ility, frequency of urination, dysuria, and cloudiness 
of the urine. The i)ossibility of previous attacks of i)elvic jjeritonitis, 
as well as of dyspareunia, painful defecation, etc., should Ije incjuired 
into. In eliciting information much tact is necessary, and especial 
care should be taken to avoid wounding the patient's .sensibilities. If 
the patient is a married woman, the questions should be so framed as to 
be entirely free from all suggestion of marital contamination. 

Preparation of the Patient for a Gynecologic Examination. In 
making an office examination, the ])hysician should safeguard himself 
by having a reliable thij-d person present. If he employs an oflice 
niM-se, her presence is sufficient; if not, the patient slioiiM lie dircctc)! 



to bring an elderly woman, preferably her mother or an older sister, 
with her. The day Ijefore the examination the bowels should be thor- 
oughly moved by a cathartic. In general gynecologic work it is usually 
customary to instruct the patient to urinate just before coming for 
examination. When gonorrhea is suspected the patient should be 
instructed not to urinate for four or five hours previous to the examina- 
tion, so that if a purulent discharge is present in the urethra, its pres- 
ence may be noted and an abundant amount obtainable for the bac- 
teriologic examination. After cultures or smears have been taken, the 
bladder may be emptied. For similar reasons the patient should not 
take a vaginal douche before being examined. 

Examination Table. — This should be so arranged as to secure a 
good light. This is a very important point. Although daylight is 
preferable to artificial light, the latter is so much more certain as to be 
almost a necessity. Care should be observed to select a powerful 
light, but one that can be so arranged as not to shine in the eyes of the 
physician during the course of the examination. A toilet and special 
examining room is of great advantage, insuring privacy for the patient 
both before and after the examination. If this is not available, the 
examining table should be completely screened off from the rest of the 
room. The patient should be directed to loosen all clothing about the 
waist and to remove the corsets. This is necessary not only for the 
abdominal examination which usually precedes the pelvic examina- 
tion, at least in all new cases, but is essential for the making of a satis- 
factory pelvic investigation. 

The variety of examining-table to be used is largely a matter of 
preference. A table that is moderately high, that inclines slightly 
away from the examiner, and that permits the patient to get on and 
off without difficulty is most to be desired. The top should be well 
padded, but not soft. One or two firm pillows are almost a necessity. 
One of these, placed under the patient's head, not only adds greatly to 
her comfort, but tends to relax the abdominal muscles. A jaillow may 
also be used to elevate the pelvis when the patient is in either the dorsal 
or Sims' position. The examining-table should contain a drawer for 
holding instruments, or a special small table may be utilized to hold 
them, as well as the various medications and tampons, etc., that are 
likely to be required. Great care should be exercised throughout the 
entire examination to avoid unnecessary exposure of the patient. 
For this purpose one or two sheets are usually employed. These 
should be so draped as to permit the examiner to make a thorough in- 
spection, with as Uttle exposure of the patient as possible. Indeed, if 
this part of the examination is cleverly performed, the patient rarely 


knows that she has been exposed at all. It is absolutely essential, 
howe\'er, that a thorough inspection be obtained. 

Instruments and Lubricants Required in Making a Gynecologic 
Examination. — For the ordinary pelvic examination the instruments 
necessary are two tri valve or bivalve specula of different sizes, a 
Sims' speculum, a double tenaculum forceps, a pair of long, stout 
dressing forceps, and four applicators. The last are used for securing 
specimens for bacteriologic examination, a fresh instrument being 
used in each location. This is done to obviate the danger of carrying 
infection from one area to another. If the operator has a small al- 
cohol lamp at hand, one applicator will be sufficient, its point being 
sterilized in the flame each time it is employed. Small slivers of steri- 
lized wood (tooth-picks, for example) may be substituted for the metal 
applicators. These may be held with a pair of applicating forceps 
while in use, their ends being covered with sterile cotton. The wooden 
applicators should be used only once and then destroj'ed. \\lien there 
is a sufficient amount of secretion, and in all cases of vaginitis in chil- 
dren, the best instrument for securing material for bacteriologic ex- 
amination is a medicine-dropper, or a small glass syringe to the end of 
which a small soft-rubber nozle, about an inch or two in length, has 
been attached. 

Van Gieson' has compared the results obtained by the use of cotton 
swabs with those secured by using the medicine-dropper, and finds 
that, with the latter, a considerably larger proportion of positive re- 
sults were olitained. This is due to the fact that with the swab method 
the solid particles of secretion are caught in the fibers of the cotton, 
with the result that the material placed ujion the cover-glass consists 
largely of serum. The mechanical trauma incident to attempting to 
transfer the discharge on the swab to the slide is often suflicient to 
injure or destroy the leukocytes or epithelial cells, thus making the 
detection of the gonococci and their intracellular demonstration more 
difficult. The intracellular establishment is an essential feature in 
the rccnfriiiticjn of the organism. Apart from this, removal of thick, 
tenacious material, such as is found in the cervix, from the swab 
to the slide, is usually difficult. The application of the swab is also 
usually painful, and in cases of vaginitis in children frequently harm- 
ful. On the other hand, a medicine-dropi)er with a small .soft-rubber 
nozle can be easily and i)ainlessly introduced into the vagina. If 
the secretion is scant\' and cultures are not to be taken, the medicine- 
dropper may be partially filled with Ijichlorid solution, 1 :.")()()(). This 
is introduced into the vagina of the child, and, by c(mii)ressing and 

'VanGioson: MpiJ. Rcconl, June, HtlO. 


expanding the bulb a few times, an emulsion of the exudate is formed. 
Another advantage of this method is that by it the entire vaginal 
contents may be obtained. The liichlorid fixes the cellular elements, 
and when dried on the slide, they are of perfect form. If necessary, 
the collected fluid may be centrifuged. This method is also useful 
in securing material from cases of ophthalmia. \^^ienever possible, 
in obtaining material for bacteriologic examination from adults, the 
pipet should be substituted for the swab. 

An excellent instrument for obtaining a specimen of the suspected 
secretion from women is a blunt-pointed, dull, narrow-bladed bistoury. 
The small sharp spoons now made also answer the purpose admirably. 
Dufaux^ has devised a little instrument for this purpose; it is shaped 
like a finger, and answers the same purpose in forcing out the con- 
tents of the glands, whereas the back is hollowed out to catch the 
droplet of secretion expressed. 

It is sometimes advisable to collect the secretion for examination 
in thin glass or capillary tubes, sealing the ends of the same over the 
flame. The exudate thus secured may be employed for making cul- 
tures or smear preparations. For cultures it is inferior to direct in- 
oculation. To make the smears, clean glass microscopic slides are 
required. These are best kept in a 70 per cent, alcohol solution, 
which sterilizes and keeps them clean and from which they may be 
taken for use as required. WTien cultures are to be made, test-tubes 
containing the media and four platinum loops with which to obtain 
the suspected secretion are necessary. In the ordinary case, these 
instruments will suffice. When, however, it is found necessary to 
examine the bladder, cystoscopic instruments will be required. In a 
case of unruptured hymen a large or medium-sized cj'stoscope may 
be used through which to inspect or treat the cervix or vaginal walls. 
This is also of use in making examinations of the urethra in cases of 
ulcers, localized areas of inflammation, strictures, or chronic ure- 

For rectal examination, a proctoscope will also be required. The 
type of instruments employed is largely a matter of individual choice 
with the operator. Electric batteries can now be obtained, from 
which hghts may be introduced not only through the cystoscope and 
proctoscope, but also through the ordinary vaginal speculum. These 
lights are often of great assistance. The routine employment of 
rubber gloves is an advantage. Not only is the danger of infection 
to both patient and operator minimized by their use, but the surgeon's 
hands are spared the frequent hard scrubbings and long immersions 

' Dufaux: Deut. mod. Wopli., Berlin, 1912, vol. xxxviii, No. 5. 



in antiseptic solutions, which have a tendency' to roughen the skin and 
make its steriUzation more difficult. Their use also tends to save 
much time. An operator soon becomes accustomed to wearing rubber 
gloves, and learns to palpate quite as accurately' with them as with 
the bare hand. But one glove need be worn, the hand on the abdomen 
being left bare. Gloves are best put on dry after sprinkling powder 
inside them, care being taken, however, not to allow an excess of powder 
to be deposited in the tips of the index- and middle glove-fingers, as 
the latter will impair the tactile sense. All instruments and gloves 
should be sterilized before being used. 

Excellent lubi-icants are now manufactured I)y most of the physi- 
cians' supply houses. These are stored in a convenient form in col- 
lapsible metal tubes. The chief requisites of a lubricant are that 
it be easy of application, non-irritating, water-soluble, non-greasy, 
non-corrosive to instruments, aseptic, and easily removable from the 
hands. Glycerin is a good lubricant, and is soluble in water. Vaselin 
and other substances exhibited in cups or wide-mouthed bottles 
should be avoided, because of the danger of contaminating the cups 
and thus inoculating subsequent patients. This objection may be 
overcome by sterilizing a number of small \\ade-mouthed bottles of 
vaselin and using a separate bottle for each case. At best, vaselin is 
not a satisfactory lubricant. 

Position for Examination and Local Treatment. — The position 
in which the patient is to be placed upon the table varies with the 
case. In this country the dorsal, or hthotomy, position is the most 
popular, whereas in England the Sims' left lateral position is very 
generally employed. It is in onl}' rare instances that it will be found 
necessary to use the knee-chest or other postures. The dorsal position 
varies somewhat according to the table that is employed. The most 
satisfactory tables are those having stirrups in which to place the feet. 
These stirrups are on a level with, or shghtly above, the table, and 
are arranged on a movable arm, so that the position of the foot-support 
may be ])laced either nearer to, or farther from, the table, to suit the 
comfort and convenience of the patient. If bimanual paljiation is 
difficult, further relaxation may be obtained l^y flexing the thighs 
upon the abdomen. This is known as the gluteodorsal position, and 
may be attained either by having an assistant support the limbs or 
by placing the patient's feet in elevated supports, such as are usually 
employed for plastic operations. At the same time the jiatient's 
l)Uttocks should be brought well down over tlic edge of the table. 
When the patient is to be placed on the table in tlic dorsal position, 
the clothing should be loosened about t he The nurse or operator 


takes a position in front of the patient, placing a sheet so that it will 
extend from her chest to the floor. The patient should stand im- 
mediately in front of the examining table, and be instructed to raise 
her clothing to the waist, and then to sit on the edge of the table. 
Next she lies down on the table, and her feet are raised and placed in 
stirrups. The sheet should at all times entirely cover the patient. 
A pillow is then placed under the patient's head, and the sheet so 
arranged as to expose the genitaUa. The examination should then 
be proceeded with in a routine, systematic manner. 

Method of Performing Routine Examination and of Obtaining 
Material for Bacteriologic Investigation. — The external genitalia 
should first be inspected, giving special attention to any inflammations, 
reddened areas, ulcers, or papillomata that may be present. The 
amount and character of the discharge should be ascertained. The 
condition of the hymen should be determined, for although the in- 
tegrity of this membrane is not an absolute proof of virginity, the 
fact that it is ruptured is strong presumptive evidence of unchastity 
in the unmarried. 

The next point to be examined is the opening of Bartholin's glands. 
The vulvovaginal glands, as they are termed by Huguier, are the 
analogue of Cowper's glands in the male, and are situated in the lower 
and posterior portion of the labia majora. They are rounded struc- 
tures, somewhat flattened anteroposteriorly, and vary in size, even 
in the same individual. Usually the glands are about the size of an 
almond, and in thin women they can often be felt as a distinct thick- 
ening; in stout patients, in those who have not reached puberty, and 
in old age, palpation of these structures is usually impossible, ^^^len, 
however, an infection is present, the glands can easily be outlined 
from the surrounding parts by their hardness and induration. 

Frecjuently, in bartholinitis, only the duct of the gland is involved. 
The orifice of the duct is situated about 0.5 cm. in front of the hymen, 
or carunculse myrtiformes, as the case may be, and at a point slightly 
below the junction of the middle and lower third of the labia minora, 
on the inner surface of these structures. The duct is about 1 or 2 cm. 
in length. Inflammation of any type, involving either the gland or 
its duct, causes a reddening about the opening. Inflammations of 
these regions are nearly always gonorrheal in origin. The tj^pical 
macula) gonorrhoicse of Sanger consist of reddened, elevated areas 
about 3 to 5 mm. in diameter, firmer than the surrounding tissue, and 
somewhat resembling, in appearance, a mosquito-bite or flea-bite, 
the extreme center being dark red and elevated. Frequently, how- 
ever, the only evidence of infection is a slight reddening or discolora- 


tion about the orifice of tlie duct. In those cases in which gonorrhea 
is suspected the labia should be retracted, and the inner surface wiped 
dry with a piece of sterile cotton. Pressure should then be made 
directly over the gland, downward and outward, milking the gland 
and duct throughout their entire length. In the normal individual, 
if this has been properly performed, a small drop of clear mucus will 
be extruded from the gland opening. If this secretion is turbid or 
purulent, infection may be strongly suspected. A clear discharge is 
not, however, positive proof of the absence of gonorrhea. Smears 
should be made, or cultures taken from the secretion of both sides, 
and labeled B. R. and B. L., according to the side from which they 
have been obtained, or the operator may make a routine habit of 
examining various points in succession, and number the slides accord- 
ingly. Thus Xo. 1 would invariably indicate the secretion from 
Bartholin's gland on the right side; No. 2, from that on the left, and 
so on. The urethra should next be examined, particular attention 
being directed toward reddening of the external urinary meatus. The 
external orifice should be wiped dry with sterile cotton, and the urethra 
milked rather vigorously throughout its course. The secretion thus ob- 
tained may be used for making smears and cultures, these being labeled 
'"U" or No. 3. In chronic cases the gonococci are most frequently 
found in Skene's ducts, which are situated in the floor of the urethra, 
just within the orifice. In the multipara the openings of these ducts 
are usually readilj^ seen, but in women who have not borne children it 
sometimes becomes necessary to dilate the external minary meatus 
slightly before a good exposure can be obtained. If infection is 
I)resent, these structures can usually be discerned as small, reddened 
pits from which, when pressure is exerted beneath them, a small drop 
of pus often exudes. In order to secure secretion from them for 
bacteriologic examination a small probe may be used gently to scrape 
the floor of the urethra over Skene's ducts, and in suspicious cases 
it may be inserted a short distance into the glands themselves. A 
capillary tube, with a small bulb attached to one eiul to effect drainage 
of the exudate into the tube, is also an excellent instrument to use for 
this purpcse. All such material may be set aside and labeled '"S". 
The next organ to be examined is the cervix. To do this the labia 
should be separated and wiped dry with sterile cotton, to avoid the 
clanger of carrying infection from the external genitalia to deeper, 
l)erhaps uninfected, organs. If cultures are not to be taken, tlie ex- 
ternal genitalia and inner sides of the labia are best s])onged with a 
1:1()()() bichlorid solution. Anti.septics should not be employed if 
• uiturcs arc to ix- taken, for their use ma>' iiiliiliit i)acterial growth. 


The cervix is now exposed through a suitable specukmi. The bivalve 
or trivalve speculum is usually employed for this purpose;' it should 
be introduced with the edges parallel to the long axis of the body, and 
after it has been inserted an inch or two, rotated. When inserting 
any instrument into the vagina, it is important to make the necessary 
pressure backward toward the rectum, rather than forward or later- 
ally. Before attempting to open the speculum it should be pushed 
in as far as is necessary, going somewhat downward and posterior to 
the supposed location of the cervix. A non-observance of this detail 
will permit the anterior vaginal wall to roll out in front of the cervix 
and obstruct the view of this structure. 'Wlien possible, it is best to 
ascertain the position of the cervix by the touch before introducing 
the speculum. The cervix being exposed, its general appearance is 
observed, its size and the character of the discharge noted, as well as 
the presence of any areas of inflammation. Of especial significance 
in the nulhpara is a reddened area immediately surrounding the ex- 
ternal OS. This is occasionally simulated by a congenital erosion of 
the cervix, but this condition is easily differentiated from a gonorrheal 
cervicitis. The cervix should next be swabbed with bits of sterile cotton, 
the thick, tenacious mucus that is present at the external os being re- 
moved as thoroughly as possible. A single smear or culture may now 
be taken from the secretion just within the external os. The cervical 
canal should now be dried further by means of small pledgets of sterile 
cotton. It is important that as much mucus as possible be removed 
from the canal. ' The cervix is now best fixed with a double tenaculum, 
and squeezed firmly either with the fingers or with forceps, or the lower 
portion of the canal may be slightly dilated, the material for bacterio- 
logic examination being then removed from a point well within the cer- 
vical canal. Firm compression of the cervix is made in order to obtain-, 
the secretion from the cervical glands and from the deeper crypts of the 
canal, areas in which, in chronic cases, the gonococci are particularly 
likely to linger. The specimen thus obtained may be labeled " C " when 
it was taken from the cervix, or "C. C." when obtained from the cer- 
vical canal. If the patient to be examined is a A'irgin, the intra vaginal 
manipulations can usually be performed through a large-sized cysto- 
seope, without resulting injury to the hymen. In these cases it is 
sometimes best to administer an anesthetic. After having obtained a 
specimen for bacteriologic examination from the vulvovaginal glands, 
urethra, and cervix, the usual pelvic examination may be made, especial 
attention being directed toward detecting adhesions of the uterus or 
its appendages, and enlargements or lesions of the latter. 

Asepsis in Gynecologic Examination. — In all forms of gynecologic 


work strict asepsis must be maintained. This applies to examina- 
tions and treatments, as well as to operations. In making the routine 
examination laxity regarding asepsis will result not only in contamina- 
tion of many previously uninfected cases, but will prove a bar to 
successful treatment. 'N^Tiere a number of cases are to be examined 
in succession, infection is particularly likely to occur unless thorough 
asepsis is carried out. Although the routine use of rubber gloves 
does much to lessen this hkelihood, the observance of the usual pre- 
cautions should not be neglected. Before each case is examined the 
hands should be washed and immersed in an antiseptic solution. All 
instruments and dressings should be sterilized. A good plan is to 
have two sets of examining instruments, one set being allowed to boil 
while the other set is in use. 

Sims' Left Lateral Position. — Xot infrequently, for purposes of 
inspection or for obtaining specimens for bacteriologic examination, 
the patient is placed in Sims' left lateral position. This posture 
has the advantage of being less tiresome for the patient than the 
dorsal position, but when palpation is to be performed, the former 
position is much inferior to the latter. In the Sims' position the 
patient lies on her left side, with the knees flexed nearly at a right 
angle with the thighs, the latter "being similarly flexed on the abdomen; 
the right leg is more markedly flexed than the left, and the pelvis is 
tilted so that the right knee rests above the left and on the table. If 
the table is a narrow one, the left arm may be allowed to hang over 
the edge; if not, the arm should lie behind the back. The trunk 
should be so rotated as to bring the breasts in contact with the table. 
A firm pillow placed beneath the pelvis increases the inclination of 
the latter and is often of assistance. The examiner may now proceed 
in the usual manner, except that a Sims' speculum is substituted for 
the bivalve type. If the patient is placed properlj' in the left lateral 
position, the vagina will balloon out with air as soon as the speculum 
is introduced. An exception to this may be found in patients suffering 
from extensive pelvic adhesions. 

Knee-chest Position. — In rare instances it maj* be found advisable 
to place the patient in the knee-chest posture. When this is done, 
the patient assumes the attitude of Eastern supplication, except that 
the face is turned to one side. The knees are brought to the edge of 
the table, the thighs being perpendicular. Success in both the knee- 
chest and the Sims' position depends on the proper tilting of the pelvis, 
which will permit the intestines to gravitate out of it; as a conse- 
(luence, when the speculum is introduced, the vagina becomes filled 
with air. In both positions it is essential that the spiii(> be relaxed 


and the back bent forward. The knee-chest, or, as it is sometimes 
termed, the genupectoral position, is so trying for the patient that 
it is rarely employed in ordinary examinations. By its use, however, 
an excellent exposure of the entire vagina and cervix may be secured. 
For ordinary purposes the dorsal position is the preferable one, and 
if a table that permits the lower end to be elevated is employed, the 
intestines will gravitate out of the pelvis almost as well in this posi- 
tion as in either the Sims' or the knee-chest posture. 

Examination of Patients in Bed. — Under some circumstances it 
may be necessary to examine patients in bed. In such cases the 
woman should be turned on her side, and the buttocks lifted well over 
the edge of the bed, the limbs being supported by assistants or allowed 
to rest on chairs. A pillow should be placed under the head. For 
purposes of palpation only the patient may lie on her back at the side 
of the bed, covered with a sheet and with her knees drawn up. The 
examiner sits on a chair beside the bed, to the left or right, according 
to the hand he is accustomed to employ in making vaginal examina- 
tions. Bed examinations are, as a rule, much less satisfactory than 
are those performed on an examining table. 

Methods of Palpation. — In performing palpation of the pelvic 
organs, many methods are employed for securing relaxation of the 
patient's abdominal and pelvic muscles. On introducing the fingers 
into the vagina, pressure should be directed backward, and every 
effort made to avoid manipulation of the clitoris. The utmost gentle- 
ness is essential if a satisfactory palpation of the intraperitoneal 
generative organs is to be made. When a patient complains of pain 
or tenderness on one side, it is best to examine the opposite side first, 
for by palpating the diseased area at once, the patient will involuntarily 
contract her muscles, and thus render the remainder of the examina- 
tion more difficult. One of the best procedures for securing relaxa- 
tion of the abdominal muscles is to have the patient take deep breaths 
and keep the mouth open. It is essential to gain the confidence of the 
patient, for if she is frightened and fearful of being hurt, relaxation is 
rarely obtainable. For this reason the first steps in the exaixiination, 
especially if it is the first examination, should be performed with the 
utmost gentleness, and if it is necessary to palpate tender structures, 
this should be done last. 

Sonnenfeld' directs that the patient clasp her hands and pull 
vigorously. This will help to distract her attention from the examina- 
tion, and thus facihtate the latter. It has been suggested that in 
cases in which there is marked rigidity over the lower abdomen, pressure 
be made slightly above the umbilicus by means of a broad leather 

1 Sonnenfeld: Monats. f. Geb. u. Gyn., 1910, vol. xxxii, p. 572. 


strap or sheet twisted into a rope for five or ten minutes, by which 
procedure, it is claimed, the recti muscles become tired and relaxation 
is obtained. 

Structures can often be more easily palpated if the cervix is grasped 
with a double tenaculum forceps and drawn downward toward the vagi- 
nal outlet. By placing his foot on a stool or on the rung of a chair, 
resting the elbow. of the examining hand on his knee, or by pressing 
his elbow against his side, the operator will be enabled to dispense 
with much of the muscular effort of the forearm that is usuallj^ re- 
quired in making an examination, and that interferes with the fine 
sense of touch. Examinations should be conducted in a routine, 
systematic manner, each organ in turn, whether diseased or not, being 

The Use of Anesthesia in Gynecologic Examination. — In cases 
that present any especial difficulties in the way of making a thorough 
examination or formulating a diagnosis, and whenever an adult pa- 
tient is presumably a virgin, an anesthetic should be employed. 

Rectal Examination. — Whenever it is deemed necessary to follow a 
vaginal examination by a rectal one, the danger of carrying infection 
from the genitalia to the bowel must be borne in mind. The perineum 
and anus should be carefully cleansed with an antiseptic solution, and 
clean gloves and instruments employed. 

Rectal examinations are of especial value to the gynecologist in 
examining those patients in whom the hj-men is intact. Not in- 
fre(iuentlj' deeply placed structures can be more definitely outlined 
through the rectum than through the vagina. It is possible, by this 
method, to examine the posterior surface of the uterus. 

Bacteriologic Examination. — The next step in the examination 
is the staining of the smear preparations. This can best be deferred 
until after the patient's departure. In all cases in which microorgan- 
isms resembling the gonococci are detected the Gram method of staining 
should be employed. In medicolegal cases, and especially in suspected 
cases in which the findings have repeatedly been negative, cultures 
.should be made. In bacteriologically negative cases that present 
clinical .symptoms of gonorrhea repeated examinations should be made 
in an effort to demonstrate the i)resence of gonococci. The methods 
of conducting such examinations, and the periods at which they are 
most likely to i)e successful, have previously been described in 
Chapter II. Unfortunately, the acute stage during which gonococci 
can usually be easily demonstrated in the discharge is also the time 
when a bacteriologic examination is least useful, as at this period a 
diagnosis may generally be made from tiic clinical symptoms alone, 


whereas in the latter stage, when the disease lias become chronic, it is 
often extremely difficult to demonstrate the presence of the specific 
organism. When clinical symptoms of gonorrhea exist and in the ab- 
sence of the microorganisms in the secretions, as instanced by negative 
smear preparations, the case is best regarded as one of gonorrhea, at 
least until a number of bacteriologic examinations, conducted under 
favorable circumstances, have been performed. It is in such cases as 
these that cultures made by a skilled bacteriologist will be of especial 

Boese and Schiller^ consider that the recognition of the gonococci 
in smear preparations is not essential for the establishment of a diag- 
nosis of gonorrhea, provided the clinical manifestations of the disease 
are present in the lower genital tract. 

After the clinical symptoms of gonorrhea have subsided, all 
patients should be subjected to repeated — at least three — thorough 
bacteriologic examinations performed under circumstances favorable 
for the detection of the microorganisms before they are pronounced 
cured; if unmarried, they should be instructed to return for further 
examination when contemplating matrimony or on the first appearance 
of any symptoms suggestive of a recurrence of the original condition. 
In married patients the greatest care should be exercised to obtain 
complete cure before marital relations are resumed. 

Method of Dealing with Female Gonorrheics. — It will here be 
sufficient merely to allude to what has been said in Chapter VII re- 
garding the necessity of warning all gonorrheics concerning the nature 
of their disease and its dangers, both to themselves and to others. 
In this respect the physician's position is often an .extremely difficult 
one, especially if the patient is a married woman. Under no circum- 
stances should the patient be left in ignorance as to the infectious 
nature of her disease. On the other hand, care must be taken not to 
arouse suspicion of marital infidelity in a case that may possibly be 
the result of an extragenital infection. In this respect no rule can be 
laid down to govern all cases. Under such circumstances common 
sense and tact are the essentials. An endeavor should be made to 
have the husband consult a genito-urinary surgeon, as it is obviously, 
futile to attempt to cure a gonorrhea in a woman whose husband is 
afflicted with a neglected or chronic gleet or other form of Neisserian 
infection, and who is constantly reinfecting his wife. There is no 
class of cases in which more tact, judgment, and diplomacy are required 
on the part of the physician than in the treatment of victims of marital 

' Boese and Schiller: Berlin, klin. Wochenschr., 1898, No. 26, p. .580; No. 27, p. 600; 
Ao. 28, p. 62.5; No. 29, p. 643; also Ann. de gynec. et d'obst., ParLs, 1898, vol. 1, p. 226. 



The most frequent etiologic factor in the production of inflanniia- 
tion of the vulva is the gonococcus. That gonorrheal vulvitis is not 
more often encountered among adults can be explained, to a great 
extent, by the histologic structure of this region. The covering of 
the outer portions of the vulva is similar to that of the skin, whereas 
on the iinier surfaces of the labia the stratified squamous epithelium 
becomes more delicate and gradually merges into that of the vagina. 
It is only with difficult}^ that a lesion in the skin can be produced by 
the application of pure cultures of gonococci, and were it not for modi- 
fications resulting from local conditions, such as moisture, friction, 
and discharges, vulvitis in the adult would be even less frequent than 
it is. The comparative infrequency of vulvitis in adults as compared 
with children can be explained on the ground that in the former 
the protective epithelium is tougher, better developed, and therefore 
more resistant than in the latter. The bactericidal properties of the 
vaginal and cervical secretions with which the vulva is more or less 
constantly bathed also tend to lessen the dangers of infection in this 
location. This is particularly true of the inner aspects of the vulva, 
whereas the outer surfaces possess more definitely the histologic pro- 
tective properties previously mentioned. (Jonorrheal vulvitis in 
adults is nearly always secondary to gonorrhea in other portions of 
the genital tract, and usually results from tlie irritating discharge 
thus produced. 

Symptoms. -In general these are similar to those symptoms ac- 
c()in));iiiyiMg dermatitis in other locations, but are somewhat UKxli- 
tied as a result of local conditions. liartholinilis, urethritis, and 
cervicitis are usually present. The severity of the symptoms varies 
according to tlie individual case. The onset is usually insidious, but 
may l)e abrupt. The vulva, and especially the fourchet, are red, 
swollen, and lender, and marked edema may be ijrcsnit. The re- 
sulting discharge may be tliin and milky at lirst, l)ut in a few daj's, 
if treatment is not instituted, it becomes profuse and purulent. Gono- 
cocci are present in the exudate. The tissues arc inten.sely congested, 



and in some cases the affected areas are partially covered with a pseudo- 
diphtheric membrane, beneath which ulcers may form. These ulcers 
are tender and bleed readily. The entire surface of the vulva is often 
bathed in pus, which also collects in the fossa navicularis. The carun- 
cul« myrtiformes or, in the case of virgins, the hymen, is reddened, 
swollen, and tender. Occasionally infection of the hair-follicles or 
of the sebaceous or sweat-glands occurs, and when this takes place, 
numerous small pustules are present. In neglected cases, as a result 
of uncleanliness, crusts may form about the external genitalia, and 
beneath these superficial ulcers and cracks or fissures may be present. 
In untreated cases the discharge usually gives rise to eczematous skin 
lesions on the surrounding parts. Condylomata acuminata and 
inguinal adenitis may accompanj^ the condition. The latter is 
usually bilateral, although not infrequently one side is more severely 
or extensively involved than the other. The subjective symptoms 
necessarily vary with the gravity of the lesions present. In mild 
cases these may consist only of slight itching or chafing about the 
external genitalia, whereas in the presence of severe lesions the pain 
may be intense. As a result of the passage of urine over the inflamed 
areas, the symptoms are usually aggravated by micturition. Walking 
or friction also tends to increase the subjective symptoms, whereas 
rest in the recumbent position will allay the discomfort. When the 
condition is very acute and febrile, constitutional symptoms may 
appear, and these are especially likely to be manifested if an inguinal 
adenitis accompany the vulvitis. A neglected vulvitis of gonorrheal 
origin tends to run a chronic course and to spread to other portions 
of the genital tract. The diagnosis of gonorrheal vulvitis should 
always be confirmed by a bacteriologic demonstration of the specific 
organism in the exudate. 

Treatment. — An examination should always be made to ascertain 
if the disease is secondary to a lesion in the upper genital tract; if this 
is the case, arrest of the irritating discharge is of the first import- 
ance. In making the examination to determine this point, care must 
be exercised to avoid introducing infectious material into the vagina 
from the external genitalia. (For the technic of examination see 
p. 188.) If the patient is found to be sufTering from a cervi- 
citis, a vaginal douche consisting of a gallon of bichlorid solution 
1 : 5000 should be given twice daily, after which a suitable tampon 
should be introduced. This treatment is indicated not only for the 
cure of the primary lesion, but also to check the discharge, which in 
such cases is the exciting factor in the vulvitis. Cleanliness is an 
essential feature in the treatment of vulvitis. This is best effected 



by shaving or cropping the hair of the external genitaha and by 
frequent douching of the inflamed areas with weak antiseptic solu- 
tions, such as bichlorid 1 : 8000, phenol 1 : 20 or 1 : 40, or 5 per cent. 
antipjTin. In the author's hands the last-named drug has given 
excellent results, not only because of its curative action, but especially 
for its antipsoric properties. Perrin' recommends irrigating the in- 
flamed areas with a solution of sterile yeast, and reports that he has 
had excellent results from this treatment. The solution should be 
employed sufficiently often to keep the vulva free from discharge. 
This treatment is best applied bj^ gently separating the labia and pour- 
ing the warmed solution over the affected parts. If this procedure 
does not entirely remove all the exudate, the vulva may be carefully 
wiped with [iledgets of cotton soaked in one of the following solutions: 
25 per cent, argyrol, 12 per cent, protargol, or a 3 to 6 per cent, silver 
nitrate. Webster- recommends a solution consisting of from 10 to 25 
drops of formalin, 6 ounces of glj'cerin, and 14 ounces of water. The 
strength and choice of the solution should be governed by the severity 
of the attack. A strip of gauze or absorbent cotton moistened in the 
solution may then be placed between the labia, and a soft, sterile 
vaginal dressing applied. If the condition is a very acute one, and 
is accompanied by severe pain, the application of warm lead-water 
and laudamim may be employed continuously. Hot sitz-baths con- 
taining sodium bicarbonate are also valuable. During the acute 
stage patients should be confined to bed. After the discharge has 
begun to subside, itching may become a pronounced symptom. This 
can usually be relieved by the use of a 5 per cent, antipyrin spray or 
the application of a dusting-powder, such as boric acid and acetanilid, 
equal parts of each, bismuth subnitrate, or zinc oxid. Anspach'* 
recommends the addition of 1 per cent, powdered burnt alum to the 
lead-water and laudanum. In the chronic stage, if small ulcers are 
present, their resolution may be hastened by the apj^lication of silver 
nitrate in the form of the solid stick. After each defecation or urina- 
tion the external genitalia shcnild be carefully cleanscnl with a weak 
antiseptic solution. Rectal examinations, the administration of enc- 
niata, and the introduction of sui)i)()sitories are counteiindicated in 
these and in all other cases of gonorrhea in which the possibility of 
introducing infectious material into the rectum exists. Tiiis ]ire- 
caution should be especially ob.served in those cases in which tlic 
<lischarge is profuse and is caused by an acute condition. 

' I'l-mii: Kcv. .\Iril. lie la Suisse Kom., l!)l 1, vol. xxxi, p. 7:52. 

' Wclislcr; DLsoiiscs of \Voiii(!ii, Pliilaiiclplii:! iiml I.oiiiloii, lil07. 

' Ansparli: ( lyni-coloKy and .\l)iloniiiial Siirfjcry, Krily ami NoMr, vol. i, liM)7. 


As in all cases of gonorrhea of the lower genital tract, all soiled 
dressings should be burned, the patient warned of the infectious 
character of the disease, and every prophylactic measure possible 
employed to prevent the spread of the infection. Especial care should 
be taken to avoid carrying the infection to the eye, thus preventing 
the development of ophthalmia. Coitus should be interdicted, and 
in chronic cases, where this cannot be prevented, precautionary 
measures should be adopted. When underclothing has been con- 
taminated bj' gonococcus-bearing albuminous discharges, it is better 
first to place the garments in some disinfectant solution that does not 
coagulate albumin. If they are at once put in the steam sterilizer, 
the albumin in the discharge becomes coagulated and results in the 
production of unsightly stains. 


Condylomata acuminata, verruca acuminata, or venereal warts, 
are a frequent accompaniment of vulvitis, and are found most often 
among the uncleanly. They are particularly likely to appear if 
pregnancy should take place. These tumors occur more frequently 
and attain greater dimensions in women than in men, owing to the 
fact that in the former the gonorrheal discharges are constantly 
brought in contact with the vulva, perineum, and adjacent skin sur- 
faces. The tumors may surround the anus, and on separating them, 
a fistula in ano is not infrequently found. Children are by no means 
immune, and infants and young girls suffering from vulvovaginitis 
are frequently attacked. Smith' has reported the occurrence of 
venereal warts of gonorrheal origin in an infant nineteen months old. 

The vegetations vary in size from extremely small growths to 
tumors the size of a man's fist. They may occur as discrete excres- 
cences, or they may coalesce, forming large, cauliflower-like neoplasms. 
The confluent tumors usually originate from a broad sessile base, 
whereas the discrete warts are not infrequently pedunculated. These 
outgrowths, except when they are modified by local conditions, are 
similar in color to the surrounding skin. Not infrequently, as a result 
of being continuously bathed in an irritating discharge, the warts 
become reddened or purplish in color and very vascular. Their 
surfaces may be macerated. They may be present on the vulva or 
contiguous skin surface, or, more rarely, may extend into the vagina. 
The symptoms arising from the presence of condylomata acuminata 
are similar to those of chronic vulvitis. The exudate is usually sanious, 
offensive, and highly irritating. The more vascular the warts and the 
thinner their epithelial covering, the more profuse is the discharge. 

' Siiiitli, K. R.: Amer. Gynecology, December, 1903. 

Fig. 28.— Condyloj 

Sliowing a ruse of moderately cxtei 

iibfjiit the amis and on the perineum, wh 

of numerous small growths, are present. 


*ivc venereal warts. A number of discrete oulKiowtlis may be seen 
,e on each side of the vulva oblong tumors, formed by the eoalescence 
The tumors ou the skin show clearly the pointed character of these 

ncopla.'fms. On the inner side of the right labium minus are two flattened, softened tumors, their condition 
being due to the l()cation they occupy. In this case the vulvar outlet was bathed in a purulent discharge, and 
I lie riiueosa at rln- external urinary meatus was reddened, thickened, and somewhat everted. 


The diagnosis is, as a rule, not difficult. The possibility, however, 
of syphilis being the etiologic factor should ahvaj's be considered 
liefore treatment is instituted. In general, gonorrheal vegetations 
may be distinguished from syphilitic condylomata by their smaller 
size and pointed appearance, the growths due to specific disease being, 
as a rule, fiat and broad. In neglected cases too much weight should 
not be placed upon the appearance of the growth, but other symptoms 
and evidences of syphilis should be looked for. It should also be 
remembered in this connection that both diseases may coexist. 

(-'ondylomata acuminata probably are largely toxic in origin. The 
author has never been able to demonstrate the presence of gonococci 
in these tumors, although repeated efforts have been made. The 
organisms are frequently found upon the surface and in the crypts 
of the tumors. Similar results have been obtained by a number of 
other investigators. Streptococci and staphylococci have, however, 
l)con observed. 

Treatment. — This consists in cleansing the affected area with weak 
antiseptic solutions, and checking the discharge, as described imder 
the treatment of vulvitis. After the application of the antiseptic 
solution the warts should be dried with cotton, dusted with a non- 
irritating antiseptic powder, and a sterile dressing applied. This 
t i-eatment should be repeated sufficiently often to keep the lesions dry. 
Motion should, so far as possible, be restricted. Although mild cases 
may respond to this treatment, as a rule more active measures are 
necessary. It is often difficult thoroughly to carry out this treatment in 
the class of patients among whom venereal warts are most prevalent. 
Even under the most favorable circumstances the palliative treatment 
is slow and tedious, and if the veg(>tations are of medium or large size, 
the method should be employed only as a preliminary to operative 
intervention. The type of operation selected will naturally vary with 
the size and shape of the tumors. If the warts are few in number, 
and especially if they are pedunculated, they may be snipped off with 
a i)air of sharp scissors curved on the flat, and the base of the growths 
touched with fuming nitric acid. Before this is done, the surrounding 
skin surfaces should be protected with vasclin or other greas\' sul)- 
stance. Care should be taken to remove as little healthj' tissue as 
possible, for fear of opening avenues of infection. If only one or two 
tumors arc to be excised, the operation can be performed under local 
anesthesia, a weak cocain solution or Schleich's fluid being injected into 
the base of the warts, or they may simply be cut off without employing 
any anesthetic whatever. An excellent local anesthetic that has 
gi\('n good rcs\ilts in these cases is ethyl chlorid. Sclicin' lias rcccnlly 

'Scliiin: Wicn. kliii. Wocliciisclir., vol. xviii, \u. ."). 


reported the successful treatment of 30 cases of venereal warts by 
the use of ethyl chloric! alone; he freezes the base of the tumor and 
the tumor itself. This treatment effects obliteration of the blood- 
vessels by stasis and thrombosis, and in a few days the tumors dry 
up and drop olT. If necessary, the treatment may be repeated at 
three-day intervals. The speed with which the cure is effected by 
the Schein method depends largely upon the type of tumor. The 
advantages of the ethyl chloric! treatment are that it is bloodless, 
requires no preliminary preparation, is nearly painless, and is applica- 
ble to all cases. In the author's experience, to be effective the freezing 
must be continued for four or five minutes for each tumor. This plan 
of treatment can often, with advantage, be combined with excision. 
In operations performed imder local anesthesia, when the growths are 
numerous, it is best to divide the treatment into two or more sittings. 
In many cases in which the vegetations are extensive it is preferable to 
employ a general anesthetic and excise all the growths at one opera- 
tion. If this method is decided upon, the patient should receive pre- 
liminary treatment for a few days or a week prior to the operation, 
with the view to sterilizing, as far as possible, the diseased area and 
arresting the discharge. Prior to the operation the parts may be 
painted with a 5 per cent, iodin solution. The pedunculated tumors 
are best removed with a cautery knife heated to a dull red. Those 
neoplasms that spring from a broad base can be most satisfactorih^ 
excised with the knife, every effort being made to avoid infection of 
the wound both during and after the operation. When the excision 
is completed, the wound may be closed by interrupted silkworm-gut 

Watson^ reports excellent results from the use of lactic acid in the 
treatment of these cases. Large masses are isolated and kept sur- 
rounded by strips of lint moistened in a 0.5 or 1 per cent, lactic acid 
solution, and the base of the tumors touched at intervals with the 
pure acid. Small growi;hs are painted with a strong solution or with 
the pure acid. When the field is large, the minute vegetations are 
covered with a wet dressing. These dressings are frequently changed, 
and after each change a sitz-bath is administered. Watson states 
that small masses drop off, that the growth of large vegetations is 
inhibited, and that a cure results without leaving cicatrices and 
without accompanying pain. Occasionally, if the treatment is pushed 
too energetically, an erythema is produced. This is mild in nature 
and subsides rapidly on withdrawal of the acid. On this account, if 
large areas are involved, the healthy skin should be protected by 
' Watson, D.: Lancet, London, April 13, 1912, p. 990. 


vaselin and the acid entirely omitted for two daj's out of every week. 
Tlie time required for cure by this treatment depends upon the in- 
dividual case and the extent of the growth. One case was completely 
cured in twelve days, another in seventeen days, and an extensive 
growth disappeared in seven weeks. If the discharge is not checked 
and all the vegetations removed, the disease tends to recur. Prophy- 
lactic measures, such as are recommended in the treatment of vulvitis, 
should be instituted. 

In severe cases the tumor masses may almost entirely cover the 
anus, perineum, and vulva. Under such circumstances the frequent 
wetting of the growth with urine and the contamination with fecal 
material add greatly to the discomfort of the patient and the difficulty 
of care. The most extensive growths are often seen in pregnant 
women, and the problem presented to the obstetrician under such 
circumstances is frequently a difficult one, as even with the greatest 
care and cleanUness the risk of infection at the subsequent labor is 
very considerable, especially if operative delivery becomes necessary. 
Naturally, the obstetrician must be guided by the individual case. 
Some authorities recommend excision of the tumors. This is the course 
adopted by Markoe' in the case of large condylomatous masses sur- 
rounding the vulva. Such operations freciuently precipitate labor 
and should, therefore, not be undertaken until near term. Checking 
of the vaginal discharge and cleanliness are the sheet-anchors in the 
treatment of condylomata acuminata of gonorrheal origin, and, when- 
ever possible, should always constitute the preliminary treatment to 
oiK>ration. The a])plicati()n of the a:-ray seems to produce a marked 
inhibitory action on the growth of these tumors, and if persisted in, is 
said to produce a cure in many cases. Dubreuilh- has had excellent 
results with this form of treatment. The use of the .r-ray is contra- 
indicated during pregnancy because of the danger to the fetus. 

The glands of Bartholin derive their name from Bartholinus. 
These structures were studied by Huguier' in 185(5, and were termed 
by him the vulvovaginal glands. The glands are situated in the 
lower and posterior portion of the labia majora, partly under the 
bulbocavernosus (sphincter vagina^) muscle. In some subjects they 
are entirely covered by this muscle, whereas in others they are par- 
tially ('iiiiicddcd in the spongy tissue of tlic hiillis. The glands extend 

Markoc, ,1. \V.: Hull. I,yiiiK-in llospiliil. New York, .liino, MM-', vol. viii, No. :{, p. 1 1.}. 

Dulirciiilh, \V.: .lour. <lc M('.l. <|.. Hor.loiiiix, AuRihst 11, 1!)12. 

lluKuiiT: .Mriiioins ,U- V \r:v\<'-unc ,U- .Mc'dr.-iiw, l':in.s lS,-,(i, vol. XV, p. XU . 


posteriorly to the triangular ligament. Normallj', they are about 
the size of a small bean, but vary quite markedly even in health, and 
as a result of inflammation they often become much enlarged. The 
ducts of the glands empty on the inner surface of the labia minora, 
just in front of the hymenal insertion. The glands are composed of 
numerous divisions. The infection, first of one branch and then of 
another, accounts for the recurrence of suppuration on the same side. 
The function of Bartholin's glands is to lubricate the introitus. The 
glands are the frequent lurking-place of the gonococci. The frequency 
with which the vulvovaginal gland is infected in cases of gonorrhea is 
equaled only in two other localities, namely, the urethra and the cervix. 
According to Luczny,i statistics collected from Olshausen's clinic show 
that this location is infected in 36 per cent, of all cases. Finger- found 
them infected in about 50 per cent, of his cases. Menge,^ combining 
the statistics of Bumm, Steinschneider, Fabry, Briinschke, Brose, 
and Welander, found Bartholin's glands infected in 20 per cent, of 
both chronic and acute cases. 

The frequency of bartholinitis is dependent upon a number of 
factors — the location of the gland opening, which naturally makes it 
peculiarly likely to infection during coitus; the activity of the gland 
during sexual excitation; it seems fair to assume that during the 
process of lubrication of the introitus the opening of the duct of the 
gland widens somewhat; the location of the duct opening, which 
facilitates secondary infection by gonococci-bearing cervical or ure- 
thral discharges; and, lastly, the histologic structure of the gland and 
the chemical reaction of its secretion, which favor the growth of the 

When \ulvitis is present, the glands are nearly always infected, 
whereas, on the other hand, a bartholinitis is frequently present 
without an accompanying vulvitis. As has been stated, this is one 
of the localities in which gonococci are most prone to persist. In 
many cases a vulvitis and bartholinitis have both been present during 
the acute stage of the disfease, but the infection of the vulva has either 
subsided or yielded to treatment, while that of the gland has con- 
tinued, with the result that when the patient is examined during the 
chronic stage of the gonorrhea, the vulva appears normal, while the 
glandular involvement still continues and is more or less pronounced. 

Bartholinitis has been observed as early as two weeks after the 
c)i-iginal infection, but may occur at any time during the course of a 

' Luczny: Quoted by Clark: New York Med. Jour., March 3, 1900. 

= Finger: Wien. klin. VVochenschr., 1897, No. 3. 

' Menge, K.: Handbuch der Clcschlcchtskraiiklipiten. Mcnua, 1910. 


gonorrhea — most frequently during the first year of the disease. 
Barthohnitis may inckide varying degrees of infection of either the 
duct alone or of the duct and the gland. 


If the infection is of a mild type and confined to the duct, occlusion 
of the latter may take place. The resulting cyst forms slowly, is 
ovoid in shape, and tends to bulge into the introitus. If pregnancy 
takes place, the growth of the cysts is usually more rapid. As the 
swelling increases the vaginal cleft becomes distorted. The surface 
of the tumor is smooth, and the gland exit is reddened and prominent. 
Only rareh' will these tumors show transmitted light. The cysts vary 
in size from that of a pea to that of a goose-egg. Wiener' reports the 
history of an unusual case, in which the cysts were bilateral and 
measured respectively 11 by 8 cm. and 12 by 5 cm. 

The cyst contents are viscid, colorless or yellow, or may be choco- 
late color, owing to an admixture of blood. They are usually uni- 
locular and unilateral, and are said to be found more frequently on the 
left than on the right side. They may occur at any time after puberty, 
and in rare instances develop at an earlier age. The cysts are usually 
painless, but, owing to their size, they may cause inconvenience during 
walking or coitus. Bilateral cy.sts are more prone to produce dis- 
comfort on movement than are the unilateral tumors. Not infre- 
(luently the smaller cysts are discovered only accidentally, perhaps 
(luring the course of a gynecologic examination instituted for some 
other mf)re important lesion. Indeed, in this way not infrequently 
small cysts are found the jirescnce of which has not been known to 
the patient. 

Because of extension of the infection or as the result of trauma 
the cysts may suppurate and an abscess result. These cysts are to 
l)e differentiated frf)m hernia, hydrocele of the round ligament, vaginal 
cysts, solid tumors of (he labium, perirectal abscese, and from hernia 
and cyst combined. 

Treatment, 'i'liis consists of excision of the cyst, gland, and duct. 
l'"or this purpose a vertical incision is made on the iiuier surface of 
the labia, over the tumor, antl the entire cyst is dissected out. Care 
should be taken to avoid "l)uttonholing" the vaginal mucous mem- 
l)rane. In some cases the deej) dissection may be facilitated by intro- 
iliicing a gloved finger into the rectum, pushing the tumor forward. 
Hut this procedure is to be avoided, if possible, owing to the increased 
daniicr iif iiilcct ion. If. during tlie course (if the cystectoniy. the 
' \\ iriiLT, S.: .Viiicr. .loui-. (JlhstL'i., IVhniar.v, lull', p. 'Ji'.i. 


cyst is ruptured, its removal will be facilitated by packing the cavity 
with a narrow strip of sterile gauze, as recommended by Schoenberg.' 
This distends the cyst cavity and facilitates the entire removal of 
the latter. It is better, however, when possible, to excise the tumor 
without rupturing it, as by this procedure excision of the entire cyst- 
wall is assured. Some authorities have suggested, as a preliminary 
step to the operation, the evacuation of the cyst contents and the 
filling of the cavity with paraffin, for the purpose of causing distention. 
As a rule, considerable bleeding from the depths of the wound occurs: 
this can be controlled by the introduction of a layer of buried fine 
catgut sutures. Care should be taken to leave no dead spaces. Drain- 
age is not necessary, unless infection has occurred, and at the com- 
pletion of the operation the skin may be closed by a subcuticular 
suture. The wound should be carefully guarded against infection. 
Palliative treatment, such as evacuation of the cyst contents through 
the duct and the introduction, through the latter, by means of a blunt- 
pointed hypodermic syringe, of formalin or a solution of silver nitrate, 
is unsatisfactory and usually results in recurrence of the cyst. In 
most cases simple incision is followed by similar results. 

Infection of the vulvovaginal gland by the gonococci may give 
rise to a non-suppurative adenitis. Indeed, Halle'- and other writers 
assert that an abscess is always the result of a mixed infection. Cul- 
tures from the pus of these abscesses usually show the presence 
of the colon bacillus, Staphylococcus albus, or other pyogenic micro- 
organisms, as well as the gonococcus. Infection of the duct or 
gland may be present without producing any palpable enlargement 
of either structure. The abscesses of the gland vary in size from 
one a few centimeters in diameter to one the size of a lemon, or in 
rare instances even larger. They are frequently pyriform in shape, 
the large end being directed toward the rectum. They occur as an 
accompaniment to a vulvitis, or may arise independently years after- 
ward in patients who have never suffered from inflammation of the 
vulva. The abscess may be unilateral or bilateral, and tend to rup- 
ture spontaneously on the inner surface of the labia, just above the 
exit of the duct. In exceptional cases the pus may burrow through 
the capsule of Bartholin's gland and the abscess point on the perineum 
or even in the rectum. In this manner fistulas may develop. Owing 
to the histologic structure of the gland the abscesses are likely 

• Schoenbeig: Surg., Gyn., and Obstet., 1910, vol. x, p. .309. 

= Halle: " La Bactpriologic du Canal gi'nital de la Feinmo," The^e dc Paris, 1899. 


to recur, as many as from twelve to fifteen manifesting themselves in 
a single individual in the course of a few years. The abscesses present 
the usual appearance of a suppurative adenitis. The local symptoms 
are often quite severe. The affected area is red, swollen, and ede- 
matous, and the patient complains of pain and tenderness, which 
are rendered worse by friction or walking, and are partially relie^•ed 
by rest in the recumbent position, often with the thighs somewhat 

jVIild constitutional symptoms are not infrequent. Inguinal 
adenitis may accompany the condition. In cases of old infection the 
glands may be palpable as hard, indurated bodies — the "adenitis 
glandulae Bartholinse scleroticans " of Sanger. 

Treatment. — Before suppuration has taken place rest and the 
application of hot fomentations maj^ in some cases, abort the acute 
attack. If success does not quickly follow this treatment, or if pus 
is formed, the abscess and duct should be excised immediately, a 
similar technic being employed to that described for the treatment of 
a cyst of the vulvovaginal gland. Every effort should be made to 
avoid rupture of the abscess. If this occurs, however, the abscess 
cavity should be cauterized with fuming nitric acid, pure phenol, or 
tincture of iodin. A small gauze drain should be inserted into the 
lower angle of the wound, and the upper three-fourths of the incision 
closed with interrupted silkworm-gut sutures. In performing the 
operation it is of the utmost importance that all the glandular struc- 
ture be removed in order to prevent a recurrence of the condition. If 
the abscess has already ruptured, the cavity should be packed tightly 
with gauze soaked in pure formalin before the operation is begun. 
Simple incision, cauterization, and drainage rarely effect a per- 
manent cure. In chronic cases the diseased gland should be en- 
tirclv rcmoN'cd l)v careful dissection. 

The urethra is the portion of the genital tract most frequently 
primarily infected by the gonococcus. Welander' states that gono- 
cocci were recovered from this canal in SO per cent, of his cases. 
Hriinschke- places the frefjuency at 90 per cent.; Fabry,'' at 52 per 
cent.; Steinschneider, ' at '.)! per cent.; Finger,'' at 75 to !M) per 

' Wolaiiiicr: (Quoted liy Clark; New Vcirk Mc<l. Jour., M:ircli 8, KlOli. 

' Hriinschkc: (^uotcil Ijy Stf|)hon.s()n, S.: Oplitlmlmia Ncoiiatoriuii, Loiiclori. liHIT, p. SI. 

' Kiihry: iJcutscli. iiicd. Wofhcn.sohr., ISfvS, p. -13. 

• .St<'in.schiu-i(liT: Merlin, klin. Woehcaschr., 1SH7, No. 17. 

' Fitigi'r: (Quoted by Stcphcnaon, S.: Loc.cil. 


cent.; whereas Luczny' records 85 per cent. Laser,' in 353 cases 
of gonorrheal infection, found the organism in the urethra 111 times. 
In 80 per cent, of these 111 cases there was no macroscopic evidence 
of a urethritis. Schultz' found gonococci in the urethra 78 times, 
and in the cervix, 81 times, in a series of 104 cases. Dannreuther^ 
believes that the cervix is affected three times as often as the ure- 
thra. Pryor,^ among 197 cases of gonorrhea in immoral women, 
found the urethra involved in 90 per cent. Menge,'^ combining 
the statistics of Bumm, Steinschneider, Fabry, Briinschke, Brose, 
and Welander, found the urethra involved in 95 per cent, of acute cases 
and in 30 per cent, of chronic cases. Menge's statistics agree closely 
with the author's findings. Hunner" is of the opinion that urethritis 
is usually secondary to a fresh gonorrheal inflammation of the vagina 
or cervix. There is no doubt but that, in the great majority of cases 
of gonorrhea of the female genital tract, the urethra is infected at some 
time during the course of the disease. Whether the infection occurs 
primarily in the urethra depends upon a number of factors. If the 
introitus is small or the male organ disproportionately large, or in the 
case of newly married women, primary infection in this region is likely; 
on the other hand, a gaping vaginal orifice will render the existence of a 
urethritis somewhat less probable. If, however, infection takes place 
primarily in the cervix, it is usually a matter of only a short time before 
the urethra becomes contaminated. Owing to the anatomic formation 
of the urethra, inflammation of this structure is, per se, much less 
severe than a corresponding infection in the male. The female urethra 
is about 3.5 cm. in length. The external urinary meatus has a diameter 
of about 7 mm. and, in the nuUipara at least, is usually protected by 
two small, wing-like folds of mucous membrane, the labia urethrse; in 
the multipara, however, it is not uncommon to find the external 
urinary meatus somewhat enlarged and gaping widely. When the 
canal is at rest, the mucosa lies in longitudinal folds, between which, 
especially on its vaginal surface, there are numerous gland openings. 
These correspond to Littre's glands in the male. They vary from 
simple tubular structures to complex racemose glands. Toward the 
outer end of the urethra the glands are more numerous and complex. 

' Liiczny: Quoted by Cl.ark: New York Med. Jour., March 3, 190(i. 
- La.ser: Amer. Medicine, March 17, 1900. 

^ Sehultz: Quoted by Pozzi, S.: A Treatise on Gynecology, ^\'m. Wood and Co., New 
York, 1897, p. 724. 

' Dannreuther, W. T.: Med. Record, New York, November 4, 1911, p. 921. 

» Pryor, W. R.: .4nier. Jour. Obstet., 189(5, vol. xxxiv, p. 384. 

'^ Menge, K.: Handb. d. Geschlechtskr., Vienna, 1910. 

' Hunner: Gynecology and Abdominal Surgery, Kelly and Noble, vol. i. 


On the floor, just within the external urinary meatus, are two 
large gland openings. These were first mentioned by Skene, ^ and 
later more minutely described by SchiiUer,- who occasionally found a 
third and slightly smaller gland lying in the midline between Skene's 
glands. These glands extend upward along the urethra for a distance 
of from 5 to 16 mm., and end in a culdesac. 

When the gonococcus is brought in contact with the mucous mem- 
brane of the urethra, it enters these structures and, extending through 
the cellular interstices, rapidly produces a very positive chemotaxis. 
As a result of infection the entire mucosa of the urethra becomes 
reddened, thickened, and congested. The mucous membrane at the 
external urinary meatus becomes everted and, when the labia are 
separated, presents as a reddened area. Skene's glands become in- 
flamed; the openings appear as minute yellowish spots surrounded by 
an elevated, congested zone of inflammatory mucosa. The discharge is 
thin at first, but soon becomes thick and creamy. It is j'ellowish in 
color, and may even be blood-streaked, and at this stage contains large 
numbers of typical gonococci. Pressure over Skene's glands will usu- 
ally result in the extrusion of a drop or two of pus from the gland exits. 

Abscesses may form in Skene's or other of the urethral glands. 
As the majority of the glands of the urethra open in the floor of that 
structure, these areas of suppuration have been termed suburethral 
abscesses. Huguier' is generally quoted as having been the first to 
describe this form of gonorrhea, but Kelly'' has directed attention to 
the fact that these lesions were previously described by Heys,^ to whom 
credit for this observation is due. The abscesses are generally single, 
but may be multiple. Gicerin'"' has described a rare condition in 
which nuiltiple follicular abscesses have occurred, first one and then 
another follicle being involved. Suburethral or para-urethral ab- 
scesses usually discharge their contents into the urethra, but may 
rupture into the vagina and produce urethro-vaginal fistulas. The 
abscesses are palpable as round or ovoid areas of induration or fluctua- 
tion, about 1 cm. in diameter, are extremelj^ tender to the touch, and 
usually situated near the external meatus. 

As the inflannnation subsides and the condition becomes more 
chronic, the evidences of an acute lesion begin to disappear. The 
mucosa of the canal may regain its normal .■ip])('ar:iiic(\ although it 

' .skciir, A. ,1. ('.: AiiRT. .Jimr. Olisl., isso. 

' SchiiUer: Frstschiift f. Borniird Schullze, lierlin, 1883, vol. iv, p. 10. 
' HuKuier: M6m. dc la .Soc do C'hir. dc Paris, 1847. 
' Kelly, H. .\.: Operative Gynecology, 1907. 

' Ileys, W.: Praelical Observations in Surgery, I'liiladelpliia, ISO."), p. :SOI. 
' Gicerin: Quoted by E. Finger: Die Blennorrlioe iles .Scxual-Organs urid ilirc Kimipli- 
kationcn, Leipzig anrl Vienna, 190.3, p. 300. 


usually presents evidences of inflammation long after all subjective 
symptoms of the urethritis have disappeared. If, on inspection, the 
orifices of Skene's glands are found to be reddened and the surrounding 
mucosa is prominent, this is suggestive of a previously existing ure- 
thritis. The anterior third of the urethra is the location in which 
gonorrhea persists the longest. On making pressure over Skene's 
glands, even in old chronic cases, it is usual to obtain pus or a 
little murky fluid. The fact that no pus can be obtained from the 
urethra is no evidence that a complete cure has been effected. The 
gonococci frequently lie latent in the urethra, especially in Skene's 
or Schiiller's glands, for prolonged periods, and may at any time set 
up an acute condition. Finger^ states that gonococci not infrequently 
may be found in clear watery urethral secretions. For purposes of 
diagnosis Garceau's- modification of Skene's female urethroscope is 
of advantage. 

An attack of urethritis is ushered in by a slight tickling, itching, or 
burning sensation in the urethra during and following micturition. 
In a day or two the symptoms become intensified, ardor urinse in- 
creases, and the desire to void urine becomes more marked. The 
urethritis may cause a vaginismus. If an abscess has formed in one 
of Skene's glands, the local pain and discomfort becomes much more 
severe. Gradually, as the lesions become less acute, the symptoms 
subside. Occasionally in chronic cases skenitis, as infection of Skene's 
glands is termed by Taussig,^ produces symptoms which, if a careful 
examination is not made, may lead to an incorrect diagnosis of cystitis. 
The acute attack lasts, as a rule, from one to three weeks. During 
the chronic stage, which may continue for years, subjective symptoms 
are not infrequently entirely absent, and when present, consist of 
little more than a slight frequency and an occasional tingling or burn- 
ing sensation during urination. At this time the urine is usually clear. 
Chronic gonorrhea of Skene's glands does not generally cause pain. 

Spontaneous cure of urethritis undoubtedly frequently occurs; 
the apparent chronicity in some cases is probably due to reinfection 
by the discharge from the more intractable cervical lesions. Sub- 
jective symptoms vary widely in different cases, and even in acute 
attacks are often quite mild and transitory. 

A point of importance in the diagnosis, and therefore in the treat- 
ment, of chronic cases is to determine the point of origin of the pus 
that may be obtained by pressure over the urethra; this usually comes 

' Finger: Wien. klin. Wochenschr., 1897, No. .3. 

■ Garceau: Surg., Gyn., and Obstet., January, 1912, p. SO. 

= Taassig, F. J.: Jour. Mo. State Med. A.ssoc, November, 1912, p. 137. 





On rflrartiiiK the- labia, the external urinary meatus appear.** a-i a reddeiuMl. ck-vutcU area. 
The mucosa is tliiekened and more or lesa everted. Tina is especially noticed in the labia of 
the urt'thra. The exit to Bartholin's glund on the right side is reddened, and presents the 
typical appearance of a gonococcal macule. A small drop of pus is seen exuding. As a result 
of the irritating discharge, the vulvar orifice is seen to be more or less inflamed. Tin- infeetion 
of the crypts about the urethra is well illustrated. 


from the glands, but this point can be definitely located by means of 
a cystoscope, or the patient may be instructed to urinate and the 
urethra then be milked. Urethritis may be caused by organisms other 
than the gonococcus. SippeP has recently directed attention to the 
infection of the urethra by the colon bacillus which often occurs 
shortly after marriage. 

Treatment. — Urethritis tends to become chronic, and in rare cases 
maj' eventuate in cure without any treatment whatever. Neverthe- 
less, judicious treatment tends to shorten the duration of the acute 
attack. If they do not receive treatment, the chronic cases often 
run an almost interminable course, and are a constant source of danger 
both to the patient and to others. It is this type of case in which 
treatment is particularlj^ necessary and which is too often neglected. 
The necessity of continuing treatment until an entire cure has been 
obtained cannot be overrated. The fact that at this stage subjective 
symptoms are usually absent increases the difficulty of securing per- 
sistent treatment . 

During the acute stage it is advisable to keep the patient in bed. 
If this cannot be done, she should be instructed to avoid all exercise and 
take as much rest in the recumbent position as possible. The diet should 
be restricted, especial care being taken to exclude all highly seasoned, 
greasy, or fried foods; coffee, tea, acid fruits, and vegetables should be 
intenhcted. Alcohol in all forms must be avoided. Skimmed milk is 
highly recommended. An abundance of water should bedrunk, with the 
object of procuring a bland urine. Mineral waters are often beneficial in 
these cases, not so much perhaps from any actual medicinal properties 
they may possess, as from the fact that patients are thus induced to 
drink large quantities of liquid. To guard against cystitis, small doses of 
salol, cystogen, or boric acid, or combinations of these, may be employed. 
The l)owels should be regulated and occasionally flushed by the use 
of .salines. The use of rectal enemata is contraindicated in all gon- 
orrheal conditions about the external genitalia, because of the danger 
of infecting the rectum. Hot sitz-baths often tend to alleviate })ain 
when this is pronounced. Great care should be exercised in the em- 
ployment of local treatment not to contaminate uninfected organs, 
and this is particularly true of children. If the cervix is coincidentally 
infected, a copious weak anti.septic douche should be administered 
two or three times daily. If, however, the cervix and \'agina are 
normal, every precaution should be exercised to keep them so, and 
no vaginal douches should be given. 

In all forms of urethral treatment care must be taken not to carry 

' Sippel, A.: Deut. med. Wochenschr., June 13, 1912. 


t}ie infection from the urethra to the bladd(>r. During the acute stage 
cleanliness and irrigations of the external urinary meatus and sur- 
rounding vulvar structures with warm, weak antiseptic solutions are 
all that are usually necessary. As the acute symptoms subside, how- 
ever, more active measures are indicated. These consist of irrigations 
of the urethra with various antiblennorrhagics, among the best of 
which are protargol, 0.5 to 5 per cent.; argyrol, 5 to 30 per cent.; 
silver nitrate, 2 to 5 per cent.; ichthyol, 10 to 50 per cent. Protargol 
and argyrol, owing to the fact that they may be employed in stronger 
solutions and are less irritating to the inflamed mucosa, have largely 
superseded silver nitrate. The injections may be given with an 
ordinary medicine-dropper or pipet, care being always taken to con- 
fine the treatments to the urethra, and not to wash infective material 
into the bladder. The injection should be retained for from two to 
four minutes. The patient should be instructed to urinate just be- 
fore the treatment is given and to refrain from emptying the bladder 
for at least one hour subsequently. If the urethra is found to be 
sensitive, or if the treatments cause much pain, the introduction into 
the canal of a small strip of cotton soaked in weak cocain solution 
may precede the treatment. At the completion of the irrigation a 
small pledget of cotton soaked in the germicidal solution may, with 
advantage, be introduced a couple of centimeters into the urethra 
and left in place for half an hour or longer.. If this causes much pain 
or irritation, a urethral bougie may be substituted for it. These 
bougies are made of lanolin or cacao-butter, softened with a little oil, 
to which is added protargol, argyrol, or ichthyol, as the case may seem 
to demand. 

As a vehicle for applying medications to the urethra the bougie 
possesses many advantages. After they are inserted the wa'-inth of 
the tissues causes them to liquefy slowly, thereby permitting the 
medicament to come into intimate contact with the diseased mucosa 
for a long period of time. Moreover, the oily nature of the excipient 
insures the contact of the germicide for a sufficiently long time to 
permit it to exert its full effect, as the oil tends to penetrate to the 
deepest crypts of the urethra and to adhere to the mucosa. 

Hofman' has used sodium bile salts as a pus solvent, with grati- 
fying results, in a series of cases of urethritis in the male. He believes 
that the bile salts act particularly well in removing the pus and mucus, 
thus prei)aring the field for the application of silver or other ger- 
micidal preparations. To ascertain the efficacy of the treatment 
the urethra should be examined through a cystoscope, the canal being 

' HofmMii: Wien. klin. Wochonsehr., I<tl2, vol. xxv, No. 44, p. 1742. 


first irrigated with an antiseptic solution, and care being taken not 
to introduce the instrument beyond the internal sphincter. To pre- 
vent this, the barrel of the cystoscope should not be inserted more 
than 2 or at the most 2.5 cm. Frequently, small red granular areas 
of ulceration will be found. These should be treated by direct appli- 
cations, through the cystoscope, of strong solutions of silver nitrate — 
5 to 10 per cent. These applications should be made two or three 
times a week. 

In most cases of chronic urethritis Skene's glands will be found 
to be infected. For the treatment of gonorrhea in this location a few 
drops of a 5 per cent, protargol solution may be applied, a hypodermic 
syringe with a blunt-pointed needle being employed, the end of the 
needle being inserted to the bottom of the gland. If this does not 
effect a cure in a reasonable length of time, the plan suggested by 
Skene may be used. This consists of introducing a fine probe to 
the bottom of the gland, and then cutting down on the end of the latter 
from the vaginal side by means of a cautery blade. The gland is then 
thoroughly burned out. This operation can usually be performed 
under local anesthesia. When the infected area can be easily reached, 
and when the external urinaiy meatus is large, Skene's glands may be 
opened and cauterized through the urethra. 

In examining for evidence of infection in Skene's glands, or in the 
treatment, a good exposure is most necessary. Hunner' suggests the 
employment of two bent hair-pins held in hemostats for retractors. 
Taussig- prefers an Outerbridge intra-uterine pessarj-, which has the 
advantage of being self-retaining. This authority recommends in- 
jection of 10 to 20 per cent, silver nitrate solution into Skene's glands, 
and if the infection does not quickly yield to this treatment, the in- 
cision of the glands throughout their length through the urethra. 
If an abscess is present, this should be opened, and, if possible, the 
opposite gland incised at the same sitting. These operations can, as 
a rule, be performed under local anesthesia. 

Stricture of the female urethra is of comparatively infrequent oc- 
currence. It is generally annular in type, and situated near the 
external urinary meatus, although any part of the canal may be in- 
volved. The most marked symi)tom of stricture is frequent and 
difficult micturition. The incontinence of retention, so fre(|uently 
observed in the male, may be pre.'^ent also in the female. Induration 
about the site of the stricture can usually be detected by palpation 

'Ilumicr, G. L.: Ki^lly iind Noble: Gynecology and Abdominal Surgcrj', Philadel- 
phia and London, l'.)()7, vol. i, p. 4.tL 

• Taussig, F. J.: Jour. .Mo. State Med. Assoc., November, 1912, p. 137. 


through the vagina, or the stricture may be located by means of a 
sound or with the urethroscope. If the stricture is located near the 
external urinary meatus, it may be seen by direct inspection. Not 
infrequently a stricture will manifest itself only when an old infection 
is lighted up or a fresh infection implanted upon the urethral mucosa. 
Strictures can usually be easily dilated. Forcible dilatation, with 
the patient anesthetized, and the subsequent daily passage of a sound 
for a short period, is usually preferable to gradual dilatation. In rare 
instances, owing to the density of the stricture, urethrotomy will 
be demanded, after which regular dilatation should be practised. 

During the chronic stage of urethritis general treatment is of 
secondary importance. The urine should be kept bland by the means 
previously described. In this as in all other forms of gonorrhea of the 
genito-urinary tract the patients are best confined to bed during the 
menstrual periods, as the danger of extension of the disease is greatest 
at these times. 

In itself, urethritis is frequently a very mild condition, the im- 
portance of thorough treatment depending not so much on checking 
the subjective symptoms as for prophylactic measures. For this 
reason no case of gonorrhea of the external genitalia should be pro- 
nounced cured until so proved by repeated negative bacteriologic 
examinations, conducted under circumstances favorable for the de- 
tection of the gonococcus. 


Gonorrheal vaginitis, colpitis, or elytritis is a comparatively rare 
disease in the adult. Among pregnant women and during the puerper- 
ium the condition is more common. Sanger^ states that vaginitis is 
more frecjueut in blonds than in brunets. This, however, has never 
been proved, and seems on a par with the somewhat similar state- 
ment made bj' Ricord, in 1832, to the effect that fair women were 
more inceptive to venereal infection than their darker sisters. Vagi- 
nitis may be primary or secondary, the latter form being, bj'^ far, the 
more frequent. The condition usualh' arises as the result of the con- 
stant contamination of the vagina by discharge from a gonorrheal 
cervicitis, or, less often, may extend upward from a vulvitis or a ure- 
thritis, which conditions, as a rule, accompany a specific vaginitis. 
The gonococcus is the microorganism that most frequently produces 
inflammation in this locality. The comparative infrequency of 
vaginitis in adults may be attributed to two causes, namelj^: the 
bactericidal properties of the vaginal secretion and the fact that the 
vaginal lining, which is often incorrectly spoken of as a mucous mem- 
brane, is, in general, similar in its histologic structure to the skin, 
except that in the former there are verj^ few glands and the outer layer 
of epithelium is somewhat less fully developed. Because of this latter 
reason gonorrheal infection of this area is infrequent in adults, whereas 
in children, in whom the protective qualities of the lining membrane 
of the vagina are but poorly developed, gonorrhea is often encountered. 
That the vaginal secretion is destructive to pathologic organisms 
has been proved beyond doubt. 

Doderlein believes that the acidity of the normal vagina is th(> 
result of the production of lactic acid by a special bacillus. This 
observer distinguishes between a normal and a pathologic vaginal 
secretion. The former is strongly acid, whereas the latter may be 
weakly acid, neutral, or even alkaline, and may harlior a large variety 
of bacteria, either pathologic or saprophytic, from which autoinfection 
may take place. This i)ath()logic secretion is present in oO per cent, 
of all cases of pregnancy, and is more apt to occur in the iiiullii)ara, 

' .'^iingcr: Veiliamll. il. ilcutsch. Gcsellschaft f. (lyii., 1.S.S9. 


especially if the vaginal outlet is relaxed, than in the nullipara or the 
primipara. The demonstration of this fact has greatly simplified 
the study of the process of infection. The researches of Stolz' and 
Dubendorfer^ have in the main confirmed Doderlein's conclusions 
regarding the bacteriology of the vagina. Labusquine' has also 
recently called attention to the importance of the acidity of the vagina. 

At certain periods in a woman's life the vaginal secretion tends to 
become less acid, e.g., at and immediately following menstruation, 
during the puerperium, and when a profuse leukorrhea is present — 
periods when it is well recognized, froin clinical experience, that the 
genital tract is peculiarly inceptive to any form of infection, and, more 
especially, to the gonococcus. That the vaginal secretion has bacteri- 
cidal properties is now well proved, although all Doderlein's conclu- 
sions are not universally accepted. Indeed, Kronig states that in his 
investigations he was unable to demonstrate the so-called pathologic 
secretion, and that the vaginal discharge was in all cases equally 
bactericidal. He believes that the diversity in results obtained is 
dependent not so much on the character and reaction of the vaginal 
secretion as upon the vitality and virulence of the germs. His in- 
vestigations were made upon pregnant women. An important prac- 
tical observation, reported by Kronig and since confirmed by other 
investigators, is that a solution of mercury bichlorid, when employed 
as a vaginal douche, destroys the germicidal property of the vaginal 
secretion, probably by causing a precipitation of albumin, whereas 
sterile water, employed in the same way, tends to lessen this property. 
Menge found that pathogenic germs in the vagina were destroyed in 
periods varying from two and one-half hours to three days. His 
investigations were conducted upon non-pregnant women. 

Williams'* states that, under normal conditions, pyogenic cocci 
are never present in the vagina of pregnant women, v. Rosthorn^ 
believes that the vagina is not always sterile. Pankow^ is of the opinion 
that in the normal woman there is a constant inigration of organisms 
from the vulva to the vagina, but that in the latter the organisms are 
destroyed. At the outlet of the vagina a few germs are usually present, 
but become more and more scarce as the depth of the vagina is ap- 

' Stolz: Studien zur Bakteriologie des Genitalkanales in der Schwangerschaft und im 
Wochenbett, Graz, 1903. 

2 Dubendorfer, E. : Bakteriologische Untersuchungen des Vulva und Vaginalsekretes, 
Inaug. Diss., Bonn, 1901. 

= Labusquine, R.: Annal. de Gyn. et d'Obstet., August, 1912, p. .503. 

* Williams, J. W.: Amer. Jour. Obst., 1898, vol. x.\xviii: also Obstetrins, p. 775, New 
York and London, 1903. 

^ v. Rosthorn; von Winckel, Handbuch d. Geburtshiilfe, 1903, vol. i. 

'' Pankow: Zcit. f. Geb. u. Gyn., 1912, vol. Ixxi, No. 3. 


proached. Pankow's observations bear out the teachings of Doder- 
lein, ^lenge, and Kronig as to the self-disinfection of the vagina, 
^luch investigation has been carried out for the purpose of determining 
this point. Pankow's conclusions represent the most modern view 
concerning the bactericidal properties of the vaginal secretion, and 
are accepted by the majority of investigators. Walthard found that 
streptococci from a pure culture may be injected into the ear of a 
rabbit without producing serious harm, but that if the ear was pre- 
viously ligated and the resistance thus lessened, a virulent infection 
would result. He compares this finding with that obtained when 
pathogenic germs are introduced into the normal vagina and produce 
no infection. WTien, however, similar microorganisms are brought 
in contact with the genitalia immediately after the trauma and injury 
incident to labor a virulent infection may take place, a familiar 
example of which is the ordinary postoperative infection. 

From what has been said it may be seen that although the vaginal 
secretion possesses definite germicidal properties that are more pro- 
nounced at certain times and that vary under different conditions, 
the exact cause or process by which the microorganisms are destroyed 
has not been conclusively determined. Lack of oxygen can hardly 
be considered an important factor, despite the fact that the bacteri- 
cidal properties of the vaginal "secretion are lessened in patients in 
whom the introitus is gaping, since many germs that are anaerobic 
are nevertheless destroyed. Nor can the bactericidal action be 
explained solely by the chemical composition of the vaginal secretion, 
as the reaction of the latter is found to vary quite markedly; neither 
does it seem probable that this destructive power is entirely dependent 
upon the action of a special bacillus, although some microorganisms 
are known to be antagonistic to others. According to Kronig, the 
germicidal property of the vaginal secretion is not due to the presence 
of leukocjies, as it has been found to continue after exposure to heat, 
which destroys the contractile power of cells. Our present 
knowledge of this subject would seem to show that all these factors 
pl;iy a part in the protection of the vagina, not least among which 
sliould be mentioned the resistant power of the vaginal lining niem- 
lirane, the paucity of glands in this location, the constant outward 
flow of the vaginal secretion, and its actual germicidal action. 

The production of a gonorrheal vaginitis is usually dependent 
upon the repeated or constant application of the specific microorgan- 
isms to the parts, in conjunction with irritalion or injury, or upon 
some general condition that lessens the resistance of the lining mem- 
brane. The latter is the cause of the fretiuency of vaginitis among 


children, in whom the membrane is thin and the outer layers of the 
squamous epithelium are undeveloped. The frequency of vaginitis, 
either specific or otherwise, in the aged may be attributed to the 
atrophic changes that occur in the lining membrane of the vagina. 

As has previously been stated, gonorrheal vaginitis in the adult 
is usually a secondary condition to infection of the cervix. The con- 
stant drenching of the lining membrane of the vagina with the dis- 
charge from a cervicitis tends to soften and macerate the protective 
vaginal epithelium, and is an important etiologic factor in the pro- 
duction of this form of inflammation, and also explains why the disease 
nearly always occurs secondarily. Indeed, Bumm kept gonococci 
in the vagina of an adult for twelve hours without producing a lesion. 
Sanger believes that the vagina is attacked only when the epithelium 
is delicate, thin, or of impaired vitality, such as is seen in the young, in 
the old, and during pregnancy. Mandl examined tissue taken from 
cases of acute gonorrheal vaginitis, and found that the squamous epithe- 
lium was invariably thinned, and that in many cases the papillse were 
almost exposed. The entire sections were deeply infiltrated with the 
products of inflammation, and gonococci were found throughout the 
thicknesses of the epithelium, many being within leukocytes. In 
some areas gonococci were observed in the subepithelial connective 
tissue. The gonococci were found to have penetrated most deeply 
in those areas in which the protective epithelium was thinnest. 

Symptoms.^Gonorrheal vaginitis may be acute, subacute, or 
chronic, the last being much the most frequent in adults. In the 
acute variety the onset is characterized by burning pain and tender- 
ness, which are usually referred to the vulva and the perineum. These 
are mild at first, but in a day or two they become quite severe, and 
are intensified by walking or exercise of any kind. At the outset the 
discharge is scanty and thin, but it soon becomes profuse, mucopuru- 
lent, creamy in consistence, greenish or yellowish in color, and in 
severe cases may be blood streaked. As a rule, defecation is painful. 
Patients occasionally complain of a sensation as of a foreign body 
within the vagina. Ardor urinse and frequency of urination, as well 
as other symptoms of a urethritis, are generally present. If compUca- 
tions, such as suppurative adenitis or intraperitoneal infection, are 
absent, the constitutional symptoms are, as a rule, mild. On ex- 
amination the vulva is often found to be involved, and th6 urethra 
usually presents evidences of inflammation. The lining membrane 
of the vagina is swollen, reddened, and exquisitely tender. On palpa- 
tion, the vagina will be found to be warmer than normally, and a 
vaginal pulse can often be felt. The affected parts, as well as the 


introitus, will be bathed in secretions. The hymen or the carunculEe 
myrtiformes are thickened, congested, and painful. The cervix will 
nearly always be found to be the seat of an inflammation, and oc- 
casionally the inguinal lymph-glands may be involved. The acute 
attack usually lasts for from one to three weeks, and if not properly 
treated, gradually merges into the chronic stage. / 

Gonorrheal vaginitis may be subacute from the onset, and may 
quickly verge into a chronic condition. In chronic vaginitis the symp- 
toms are usually combined with those of chronic vulvitis, bartholinitis, 
and urethritis, by which conditions it is usually accompanied. At this 
stage all the symptoms of acute inflammation have disappeared, and 
the vagina is no longer tender. The lining membrane is slightly 
reddened and thickened, and in some cases small ulcers or areas of 
erosion may be present. Finger has described a form of gonorrheal 
vaginitis in which the vagina is studded with deep-red granules the 
size of a hemp-seed, which lend to the surface a roughened, granular 
appearance. This variety of vaginitis is most common in pregnant 
women or in those who are anemic or poorly nourished. 

Small condylomatous-like outgrowths are sometimes observed in the 
vagina during the subacute or chronic stage. Some authors claim 
that these are characteristic of gonorrhea, whereas others laelieve that 
they may be produced by any long-continued irritation, and are 
merely the morphologic expression of chemical irritation of the papillse 
and their epithelial covering. Indeed, in this connection Bumm^ 
states that chronic vaginitis in the adult is not so much the result of 
an actual infection as of the chemical irritation resulting from a cer- 
vical discharge. Some authorities believe that the condition may be 
produced entirely by the toxins in the discharge. These substances 
alone undoubtedly play an important role in many cases. 

During the chronic stage the leukorrhea is decreased in amount, 
and is thinner and less purulent than in the acute stage. The more 
or less intense pain that was present during the acute stage has now 
given place to itching or burning sensations, which are increased by 
walking or friction, and are relieved by rest in the recumlient position. 
Vaginismus may l)e present, and is especially likely to occur in hysteric, 
neurasthenic, or debilitated patients. Attempts at coitus, digital 
examination, or even the introduction of the douche-nozle may pro- 
duce a spasm that involves, to a greater or less extent, all the muscles 
in the adjacent area. Vaginodynia is particularly likely to occur 
in cases in which ulcerations or fissures comi)licate the vaginitis. 
Urethritis sometimes plays a part in the prodviclion of the spasm. 

' Hmmii: Quoted by Mcngc: Handlnich der (ipschleclilskiiiiikluilcii, \iciiiia, lUH). 


The various symptoms of vuh-itis, urethritis, or inguinal adenitis 
may be present. During the acute stage gonococci in large numbers 
are present in the discharge, but later they are reduced in number 
and may be difficult to demonstrate bacteriologically. Exacerbations 
are not infrequent during pregnancy or menstruation, and are often 
erroneously regarded as fresh attacks. 

Diagnosis. — Gonorrheal vaginitis must be distinguished from 
inflammation of the vagina due to other causes, among which may 
be mentioned exogenous irritation, such as is produced by pessaries, 
tampons, and the like; from irritating discharges, such as occur in 
cancer of the uterus ; from a ruptured pelvic abscess that is discharg- 
ing its contents through the vagina; from discharges from vesico- 
vaginal, rectovaginal, or other forms of vaginal fistulas; and from 
uncleanliness. An etiologic factor to be borne in mind in vaginal 
inflammations, especially among children, is the Oxyuris vermicularis, 
or seat-worm. The use of caustics; the presence of decubitus ulcers, 
such as are often found in cases of prolapse; mycotic infections; 
irritation of the parts by dysenteric discharges ; the ordinary pyogenic 
microorganisms or the Klebs-Loffler bacillus — may all produce the 
condition. The general tendency at present is to regard all forms 
of vaginitis as dependent upon the action of microorganisms, foreign 
bodies, etc., only preparing the soil for subsequent infections. 

The diagnosis of gonorrheal vaginitis is not usually difficult. The 
history of the case, the concomitant symptoms of gonorrhea of the 
cervix, Bartholin's glands, and especially of the urethra and possibly 
of the uterine appendages, and the absence of other etiologic factors, 
are usually sufficient to establish the identity of the disease. If the 
vaginitis occurs during the puerperium and the child manifests an 
ophthalmia, this is an almost certain indication of the etiology of the 
vaginal condition, while confrontation in some cases may be possible. 
As regards the bacteriologic demonstration of the gonococcus in the 
discharge, it should be remembered that this in itself is not sufficient 
proof of the existence of a vaginitis in the adult, as the specific micro- 
organism may be recovered from the discharges in cases of gonorrhea 
of the cervix or endometrium. In order to demonstrate the point of 
origin of the specific microorganism in the vaginal secretions Schultze's 
method may be employed. This consists in thoroughly cleansing 
the vagina and external genitalia by means of irrigations and swabbing, 
and then inserting a tightly fitting tampon of sterile absorbent cotton 
against the cervix. If the secretion that collects in the vagina below 
the tampon contains gonococci, this is evidence that a specific vaginitis 
is present, whereas if the upper surface of the tampon is contaminated 


and the vaginal secretion is found to be negative, the infection is 
obviously confined to the uterus or appendages. 

Treatment. — This varies with the stage of the disease present. 
A thorough examination should first be made to ascertain the extent 
of the lesion and to determine whether it is primary or secondary. 
At this examination a specimen should be secured for bacteriologic 
investigation. If the condition is found to be secondary, treatment 
must be directed to the primary cause as well as to the vaginitis. In 
most cases, when the cervical or ureteral discharges are checked, the 
vaginal condition will improve almost at once. During the acute 
stage absolute rest in bed is indicated. The bowels should be moved 
daily, if necessary by the administration of a simple laxative, or an 
occasional dose of Epsom salts may be given. The diet should 
be similar to that recommended in acute vulvitis. As urethritis is 
usually an accompaniment of gonorrheal vaginitis, the patient 
should be instructed to drink large quantities of water, and the treat- 
ment directed for inflammation of the urethra should be instituted. 
If the suffering is severe, small doses of opium may be administered. 
Suppositories or enemata are contraindicated because of the danger 
of infecting the rectum. For purposes of cleanliness and in order to 
facilitate the local treatment it is usually advisable to shave the vulva. 
An aseptic vaginal douche, consisting of a gallon of some bland solu- 
tion, should be administered twice daily. For this purpose sterile 
water, normal salt solution, or sodium bicarbonate (4 drams to the 
gallon) may be employed, or if it does not cause too severe pain, a 
weak antiseptic solution, such as Ij^sol or creolin ( 1 dram to the quart), 
mercury bichlorid (1 :8000), boric acid (1 dram to the quart), or boric 
acid and sodium chlorid (1 dram of each to the quart), may be sub- 
stituted. The following preparation, known as the A. B. C. douche 
powder, forms the basis of an excellent vaginal irrigation that may be 
used in all forms of gonorrhea in whicli a douche is indicated: 

H . .\c. boric 5 vj 


Pulv. alum. cx.siccat aiSj 

Ol. gaulth n] 

01. inenth. pip nv xxx 

M. S. — -Tablespoonful to a gallon of water. 

The strength of this preparation may be varied, but for an or- 
dinary vaginal irrigation the foregoing quantities will be found efficient. 
Polando' states that the efficacy of a vaginal douche dei)ends upon 
its astringency — he recommends a 2 per cent, solution of alum. Next 
in order of merit this ob.server places a 4 per cent, solution of alcohol. 

' I'olando: /.■itschr. f. Ccl.. ii. <!yn„ vol. Ixx, No. 1. 


If there is no nurse in attendance, the patient should be instructed 
as to the manner of taking the douche. A fountain syringe holding 
four quarts should be employed. Glass nozles are preferable to those 
made of hard rubber, as they are more easily kept clean. Nozles 
should be of medium size, and have perforations at the side, so that a 
recurrent flow will be obtained. Nozles with an opening directly 
at the end of the bulb should never be employed, on account of the 
danger of forcing the irrigating solution through the cervical canal 
and thus infecting the uterine cavity. The nozles should be thoroughly 
washed with hot water and soap after use, and then placed in a wide- 
mouthed bottle filled with an antiseptic solution. This bottle should 
be deep enough to contain sufficient fluid entirely to cover the nozles. 
The douche-bag and tubing should be scalded well before and after 
use, and when not in use, should be preserved in a place where dust 
cannot accumulate. Only boiled water should be used for douching 
purposes. The medicament to be employed is best dissolved in a 
cup of hot water, and this mixture added to the required water in 
the douche-bag. By this method the drug is thoroughly dissolved 
and mixed with the water that is to be used. The water should, 
as a rule, have a temperature of from 105° to 110°F. The douche- 
bag should be hung at a height that will require fifteen minutes for 
two quarts of solution to run off, and twenty or twenty-five minutes 
for a gallon. As a rule, three or four feet is about the proper height. 
The douche should be taken with the patient in the recumbent posture, 
the hips being elevated. Care should be observed to keep the douche- 
nozle sterile. The labia should be separated before the nozle is in- 
troduced. A good plan is to have detailed directions for taking a 
douche printed and hand a copy to each patient. A douche-pan is 
essential. Under no circumstances should an irrigation be taken 
while the patient is on the toilet or in the bath-tub. The latter may 
seem an unnecessary warning, but many cases have been known to 
occur where this has been the custom. 

The vulvar pads should be changed frequently and the soiled 
dressing burned. Prophylactic measures, as suggested under the 
treatment of vulvitis, should be carried out, especial care being ob- 
served lest the pus be carried to the eyes. As the acute symptoms 
being to subside, more active local treatment is indicated. Vaginal 
irrigations of weak antiseptic solutions may now be employed three 
or more times daily. Formalin (40 minims to the quart), creolin or 
lysol (1 per cent.), mercury bichlorid (1 : 8000), boric acid and sodium 
chlorid (1 dram of each to the quart), potassium permanganate (1 
dram to the quart), or the A. B. C. douche are to be recommended for 


this purpose. In addition to the vaginal irrigations, local applications 
are of serA'ice. These are best given with the patient in the Sims' 
or knee-chest position; after the vagina has become distended with 
air, which should occur as soon as the Sims' speculum is introduced, 
the entire lining membrane should be freely sprayed with one of the 
anti-blennorrhagics advised for the treatment of chronic vulvitis, 
lodin, 2 grains to the ounce of 95 per cent, alcohol, answers very well 
for this purpose if the vagina be not too sensitive. The spray is more 
effective than simple swabbing, as by its means the solution is driven 
into all the crypts and folds of the vagina. In Polak's^ clinic a sat- 
urated solution of picric acid has been employed with satisfactory 
results. In about 100 cases of gonorrhea of the vagina in which the 
gonococcus was found in pure culture, from three to five treatments 
with picric acid cleared the field entirely of the gonococci. The 
method employed was very simple: the vagina was thoroughly 
cleansed; a tubular speculum was introduced, and one or two ounces 
of a solution of argj-rol were poured into the vagina. Then a suitable 
piece of gauze was soaked in a saturated solution of picric acid in 
glj'cerin and placed in the vagina. 

If chronic ulcers or abrasions are present, these may be touched 
with the solid stick of silver nitrate. This treatment should be 
thorough, and repeated two or three times a week.' After the evening 
irrigation it is often of advantage to introduce a vaginal tampon 
.saturated in one of the following preparations: Ichthyol and lanolin 
(25 per cent, to 50 per cent.) ; argyrol (25 per cent.) ; protargol (10 per 
cent, to 20 per cent.); silver nitrate (2 per cent, to 5 percent.); or 
formalin in glycerin and water (formalin, 30, minims; gl.ycerin, 6 
ounces; water, 14 ounces). Intelligent patients may be taught how 
to prepare and insert the tampons. For this purpose the antiseptic 
gelatin-coated tampons, filled with sterile wool, are best. In some 
cases, when the vagina is tender, ointments, such as carbolized vase- 
lin (5 per cent.), boric acid in vaselin, or ichthyol (10 per cent.) and 
formalin, may be substituted for the more active antiseptics. The 
tampon should be removed in the morning before the douche is taken. 
In these cases Asch- employs bougies containing 5 to 20 per cent, of 
isoform, with excellent results. This drug is said to be especially 
efficacious in the treatment of vulvovaginitis in young girls. 

In order to the amount of lactic acid in the vagina, Kuhn' 
recommends the api)licati()n of sugar. This method is of value chiefly 
in the early stages of tlic infection, ami does not prevent the eniploj^- 

' Polak : Personal communication. 

' .\.s(,'li: Zentralbl. f. Gyn., vol. xxxiv, No. 12, p. 400. 

' Kiilin: Zcit. f. Ccl). u. Gyn., vol. Ixx, No. 1. 


ment of other forms of treatment. The treatment of urethritis and 
other gonococcal lesions that may be present should not be neglected. 
It is important that these patients be kept under treatment until a 
complete cure has been effected, as gonorrhea in any form, but es- 
pecially that of the cervix and vagina, is a frequent source of infection, 
and the patient herself is in constant danger of the disease extending 
upward toward the peritoneal cavity. The fact should not be lost 
sight of that the discharge from these cases is infectious, and every 
precaution should be taken to prevent contamination of others. If 
the patient is married, an effort should be made to have the husband 
examined and, if necessary, treated. Coitus should be interdicted, 
and when this is impossible, precautionary measures should be adopted. 

These tumors may be present in the vagina, and may or may not 
accompany a vaginitis. They may be secondary to a gonorrhea of the 
cervix, or may extend inward from a vulvitis or from similar growths 
of the external genitalia. As compared with venereal warts of gon- 
orrheal origin on the external genitalia, condylomata in the vagina 
are infrequent. The growths present the same general appearance 
as do those found on the labia or the perineum. Occasionally they 
are somewhat flattened, depending upon their location. These tumors 
are most frequently obser^•ed in the lower third of the vagina, al- 
though no part of the canal is exempt. If any doubt as to the nature 
of the growths exists, a microscopic examination will clear up the 
diagnosis. The treatment is similar to that recommended for condy- 
lomata of the external genitals. In extensive excisions care must be 
observed that the vagina is not unduly narrowed, either by the opera- 
tion or by the subsequent scar. Concomitant gonorrheal lesions 
should receive appropriate treatment. 

Gonorrheal infection of the cervix is usually of primary origin, 
although ascending infections, starting at the external genitalia, have 
been described. From its location, the cervix is obviously an area 
in which contamination, resulting, as gonorrhea usually does, from 
coitus, is most likely to take place. The portio vaginalis, being 
normally covered by squamous epithelium to or slightly above the 
external os, is unlikely to become primarily infected by the gonococcus, 
an organism that shows a strong predilection for the columnar epi- 
thelium. The canal is lined with columnar epithelium, and this is 
the area in which the infection originates in the nulliparous women, 



SO that the primary infection is usually an endocervicitis rather than 
a cervicitis. From here it may spread by continuity to the surface of 
the cervix immediately surrounding the external os, and upward to 
the endometrium and to the tubes and ovaries. The process of up- 
ward extension is usually checked, at least temporarily, by the con- 
striction at the internal os. Other factors that tend to control the 
upward spread of the disease are the constant downward flow of the 
cervical and uterine secretions, the plug of cervical mucus, and per- 
haps the strong alkalinity of the uterine cavity, for it is well known that 
gonococci that have been accustomed to an even faintly acid medium 
do not grow well in an alkaline soil. The vaginal portion of the cervix 
is usually bathed in an acid secretion, whereas the uterine cavity is 
alkaline. The exact point at which this change in reaction occurs 
in the cervical canal varies in different cases. In a case of extensive 
bilateral laceration with marked eversion of the mucosa and gaping 
of the external os the acid reaction of the vagina naturally extends 
higher in the canal than in a nulli]:)ara in whom the cervical opening 
is small and contracted. 

The cervix is one of the most frequent structures in the female 
genital tract to be invaded by the gonococcus, as shown by McCann' 
and others. Menge,- quoting the combined statistics of Bumm, 
Steinschneider, Fabry, Briinschke, Brose, and Welander, found that 
the cervix was involved in SO per cent, of acute and in 95 per cent, of 
chronic cases. 

The disease may be acute or chronic, the latter being the more fre- 
quent form. Sanger, Doderlcin, and other authorities claim that gonor- 
rheal cervicitis may be chronic from the beginning. This is denied by 
Menge. Theoretically, this observer is undoubtedly con-ect, but prac- 
tically it is found that the virulence of the disease varies markedly, and 
that although all cases are probably acute at the onset, in some the 
initial symptoms are so mild as closely to approach the chronic type. 
This is true of gonorrhea in all parts of the genital tract. 

^^^len the disease is acute, the chief symptom is generally the 
presence of a profuse, thick, yellowish, purulent discharge, which 
contains polymorphormclear leukocytes, Ij'mphocytes, and epithelial 
debris, and that may at times be blood streaked. This exudate con- 
tains luunerous tyi)ical gonococci. At this stage of the disease the 
cervix may be swollen and tender. At and surrounding the external 
OS a soft, bright-red area will be found thai is more prominent than 

' McC.inn, I". .1.: Trans. London ()l>sl. Soc, ISilG, vol. xxxviii, p. 241. 
- Mcn(ic, K.: Hniidliuch d. (icscldechtskrankheiten, Vienna, 1910. 
' Dodcrlt'in: Quoted by Menge: Loc. cil. 


the surrounding tissue (Plate III), and may bleed slightly if trauma- 
tized by the examining finger. The edges of this area are not sharply 
defined, and small punctate spots may be observed extending from 
it over the adjacent portio. In the center of this area of inflammation 
is the external os, from which the mucosa of the canal may be seen 
protruding as a bright red spot of everted, thickened, and congested 
inflammatory tissue. Purulent, thick, tenacious secretion is nearly 
always present in the canal, and may be seen extruding from the ex- 
ternal OS. Pressure on the cervix usually causes pain. In those cases 
in which there has been an extensive laceration of the cervix a some- 
what more complex picture is often observed. In addition to the 
usual evidences of laceration and eversion, the mucous membrane of 
the canal may be greatly swollen; the arbor vitse may be unusually 
prominent, and the inflamed area will appear to be more extensive 
than if lacerations were not present. Constitutional symptoms are 
rarely marked and are generally absent. Slight tenderness and 
pain in the inguinal lymphatic glands and iliac regions at the men- 
strual periods is, according to Brettauer,^ a frequent symptom of 
gonorrhea of the cervix or the external genitaUa. This pain is often 
accompanied by a slight rise in temperature, and is distinctly different 
from the usual dysmenorrheic symptoms encountered in young women. / 
Menstruation may be irregular and profuse. Gonorrheal cervicitis, 
may be chronic almost from the outset. In the chronic stage leukor- 
rhea is often the only symptom present. This discharge is not so 
profuse as in the acute stage, and is usually mucopurulent and whitish 
or yellowish in color. Gonococci in reduced numbers are present in 
the exudate, and can often be demonstrated only after prolonged 
search. In chronic cervicitis acute exacerbations are particularly 
likely to occur at and following the menstrual periods, during preg- 
nancy, in the puerperium, or following unwise cervical manipulations, 
at which times the discharge is increased in amount and becomes 
more purulent. Gonococci can usually be demonstrated in the exudate 
at these periods, even in those cases in which numerous previous 
bacteriologic examinations have given a negative result. During 
the chronic stage pain is rarely observed, and tenderness is much less 
noticeable or may be absent. Menstruation may and frequently is 
irregular, and the flow may be increased in amount. Marked men- 
strual disturbances are, however, more Ukely to occur after extension 
to the corporeal endometrium. Profuse leukorrhea is, without doubt, 
a debilitating condition. The numerous reflex nervous symptoms, 
however, that are sometimes ascribed to this discharge should be ac- 

' Brettauer, S.: Amer. Jour. Obst., September, 1911, p. 4.57. 


PLATE 111 

AcrxB GoNoiiKHKAL Cbkvicitih and Uukthritis. 
The cervix in noriniil or enlarged. The area surrounding the external os is reddened and 
conKfttted. The reddened area blcnda gradually into the Hurrounding uormul cervical tissue. 
The urethra is somewhat reddened and the mucosa everted. 


cepted with great caution, as they are, as a rule, too vague to warrant 
much consideration. Cervicitis often causes steriUty. The general 
appearance of the cervix is similar to that of the acute stage, but the 
condition is more chronic. Hypertrophy of the cervix is less frequent, 
and the congestion is not so well marked as in the acute stage. As 
a consequence of infection, the orifices of the cervical gland often be- 
come occluded, and small cystic formations that vary in size from 
that of a pinhead to a buck-shot or larger result. These cysts can 
sometimes be observed bulging out from the cervical tissue beneath 
the squamous epithelium of the portio, and can be palpated as hard, 
shot-like bodies. If punctured, the cyst will exude a drop of thick, 
tenacious mucus, which may or may not be purulent. Nabothian 
cysts may result in marked enlargement of the cervix, and are espe- 
cially likely to be present in conjunction with extensive lacerations. 
In some cases of chronic gonorrhea of the cervix the lesions are so 
slight that they can be detected only with the greatest chflfiiculty. 

Diagnosis. — Cervicitis is usually readily diagnosed. To prove 
that the condition is of gonorrheal origin is, however, not always so 
easy, especially during the chronic stage. The historj' of the case 
and the application of suitable bacteriologic tests will generally clear 
up this point. When the gonorrhea is superimposed upon a laceration 
and eversion of the cervix, the diagnosis is sometimes rendered ex- 
tremely difficult. The presence of a congenital erosion of the cervix 
may also complicate the clinical picture. It should always be borne 
in mind that in cervicitis of gonorrheal origin the urethi-a and 
Barthohn's glaiuls are usualh^ involved. Severe cases of cervicitis 
occurring in multipara; may at times, on account of the discharge, 
irritation, and profuse menstruation, suggest tumor formation, espe- 
ciallj' carcinoma, and the differential diagnosis, even after the cervix 
is exposed, is not alw;ws easily made. Both lesions may bleed on 
touch, although carcinoma is more likely to do so. In carcinoma, 
however, the cervix is hard, whereas in cervicitis or in cervicitis with 
eversion it is soft. In the former there is an actual loss of tissue, 
whereas in the latter the diseased area is swollen and nabothian cysts 
are usually present. 

The history, the age of the patient, the absence or presence of 
concomitant sj'inptoms of gonorrhea in other parts of the genital 
tract, and tlu; phy.sical character of the lesions will almost invariably 
clear up the diagnosis. If any doul)t exists, a histologic examination 
of a piece of excised tissue will furnish al)solute proof of the character 
of the condition. Early 1ul)erculosis of the cervix may also, in some 
cases, confusion. In this location, however, tul)erculosis is ex- 


tremely rare. Syphilis usually presents characteristics that differ- 
entiate it from gonorrheal cervicitis. In cases of doubt, the labora- 
tory offers a means of positive diagnosis. 

Treatment. — In acute gonorrhea of the cervix no local treatment, 
save cleansing vaginal irrigations of bland antiseptic solutions, is 
indicated. As exceptions to this, however, must be mentioned those 
rare cases in which the cervical lesions are discovered in their incipi- 
ency, in which case the method of Polak^ often gives excellent re- 
sults. This consists in placing the patient in the elevated lithotomy 
position and pouring into the vagina, through a Ferguson speculum, 
a solution of 25 per cent, argyrol. The excess of the argyrol is then 
removed, and an absorbent cotton tampon saturated with a solution 
consisting of equal parts of glycerin and picric acid is applied to the 
cervix. This tampon is reinforced by another of lamb's wool. The 
tampons are left in place for twenty-four hours, and the treatment then 
repeated. By this method gonorrhea of the external portion of the cer- 
vix may often be cured in a short time, but when the disease has ex- 
tended to the deep mucosa of the canal, the treatment becomes much 
less effective. 

When gonorrheal cervicitis is chronic, every effort should be made 
to eradicate the disease. Whatever form of local treatment is in- 
stituted during the chronic stage, it is of the utmost importance, as 
a preliminary step, that the thick cervical mucus be removed, as its 
presence to a large extent nullifies the beneficial effects of all medica- 
tion by acting as a protective medium for the gonococcus, and pre- 
venting the application from reaching the diseased areas. For this 
reason, before applications are directed toward the cervix, this struc- 
ture should be exposed by means of a suitable speculum, and the 
portio and external os sprayed with an alkahne solution. This pro- 
cedure should be followed by swabbing of the canal with pledgets of 
cotton until all, or nearly all, the mucus has been removed. To 
facilitate the treatment it is advisable to steady the cervix by grasping 
it with a double tenaculum forceps. The success of the treatment of 
cervical gonorrhea largely depends upon the thoroughness with which 
this preliminary cleansing is carried out. Dobell's solution or a 
solution of sodium borate and sodium bicarbonate, of each, 1 dram to 
6 ounces of water, may be employed. For application to the cervix and 
cervical canal moderately strong antiseptic solutions give the most 
satisfactory results; among the best of these are tincture of iodin, 
pure ichthyol, silver nitrate, 1 dram to the ounce, zinc chlorid, 20 to 
50 per cent., or formaldehyd, 37 to 40 per cent. Since the cervix 

'Polak: Personal communication. 


is practically non-sensitive, these solutions may be applied with im- 
punity without causing pain. After the removal of the thick, tena- 
cious cervical mucus the vagina should be protected by the appUca- 
tion of vaselin, and the cervix and canal dried with pledgets of ab- 
sorbent cotton, and a piece of cotton or small gauze sponge placed 
posterior to the cervix. An applicator should then be wrapped with 
a thin laj^er of absorbent cotton and the solution applied to the dis- 
eased area and to the canal. Care must be taken not to insert the 
applicator beyond the internal os, but it should be pressed in every 
direction against the cervical mucosa. Sufficient medication should 
be used to reach all the crypts in the canal. If tincture of iodin, ich- 
thyol, or silver nitrate solution is employed, a pledget of absorbent 
cotton or narrow strip of gauze saturated in this solution may, with 
advantage, be left in the canal for five or ten minutes, the vaginal 
speculum being meanwhile kept in place. When the external os is 
small, it is well to dilate the lower portion of the cervical canal prior 
to making the application, so as to permit the treatment to be more 
thoroughly applied. This dilatation may be effected with the solid 
metal dilator. Superficial cysts or nabothian follicles should be 
punctured with a spear-pointed bistoury or scaljiel and their contents 
pressed out. This treatment should be followed by the introduction 
of a tampon, which may be left in place for from ten to fourteen 
hours. The cervical portion of the tampon should be saturated with 
one of the following solutions: Ichthyol, 25 to 50 per cent.; argyrol, 
25 per cent.; or protargol, 10 to 25 per cent. For office work the 
tampons put up in gelatin capsules, now manufactured by the various 
supply houses, are not only convenient, but are especially efficacious, 
as none of the solution is squeezed out during the process of intro- 
duction. These treatments should be given once, twice, or thrice a 
week. Applications should be begun three or four days after the 
cessation of menstruation, and are best discontinued a few da3's be- 
fore the expected onset of a period. The patients should be instructed 
to take three vaginal douches daily, except during menstruation: 
one in the morning on arising, one in the middle of the day, and the 
last l)efore retiring at night. (For the technic of administering 
vaginal douches sec under the Treatment of Vaginitis.) A vaginal 
douche should not he administered while a tampon is in place. The 
irrigation should consist of solutions similar to those recommended 
for chronic vaginitis, the best of which, perhaps, is the A. B. ('. douche. 
Strict asepsis should be maintained throughout the treatment. Kven 
after apparent cure has taken place the treatment .should be conliiuKMl 
for some weeks. A case should be considered cured onlv after all 


clinical symptoms have disappeared and at least three consecutive 
negative bacteriologic examinations, conducted under cn-cumstances 
favorable for the detection of the gonococcus, have been performed. 
Bruneti reports good results from the use of pure picric acid in 
these cases, and Abraham- recommends bougies containing yeast and 
aspargin The latter has treated 200 cases of gonorrhea of the cervix 
or vagina with yeast, and beheves that by this method better results 
are obtained than by the employment of any other means. His 
method is first to clean and dry the parts, and then to insufflate 
powdered yeast over the vaginal walls and cervix. As a final step, a 
glycerin suppository containing 3 grams of yeast powder is inserted 
against the cervix. This method is especially efficacious m the treat- 
ment of vulvovaginitis of children. As the result of experiments, 
Abraham found that when gonococci are brought in contact with 
yeast, they are destroyed in six hours; hence he believes that yeast 
possesses a positive bactericidal power. 

Martin^ employs steriUzed yeast applied on a tampon, and espe- 
cially recommends its use in cases of gonorrhea of the cervix complicat- 
ing pregnancy. The yeast is unirritating. This investigator prefers 
sterile normal salt solution for vaginal irrigation. Menge,^ on the 
other hand, states that yeast has been employed more or less ex- 
tensively by himself and his assistants in his clinic. No definite cure 
by the use of yeast alone has ever been obtained in any of their cases. 
Wagner" recommends irrigation of the cervix by means of hot water. 
He employs a. wire frame to distend the vagina, and irrigation with 
large quantities of hot sterile water once daily, 20 to 25 liters at 45° C. 
being employed at a treatment. Once a week mucus from the cervix 
is examined for gonococci, and the treatment is continued until no 
specific organisms have been found on three consecutive examinations. 
In 85 per cent, of Wagner's cases the gonococci had disappeared in 
from twenty-six to thirty-five days, and by the ninetieth day in all 
others. The method seems to be pecuUarly effective for gonorrheal 
vaginitis in little girls. Watson'' recommends the treatment of gonor- 
rheal cervicitis by lactic-acid bacilh. The preparation that he employs 
is made by filtering "Saurkultur" made of skimmed milk. Filtering 
separates the casein and leaves a slightly opaque whey, which con- 
tains large numbers of lactic-acid bacilli as well as lactose, lactalbumen, 

1 Brunet: Poitou ined. Poitiers, 1910, vol. xxv, pp. 10-12. 

- Abraham: Monats. f. Geb. u. Gyn., vol. xxxi. 

' Martin: Berlin, klin. Woohenschr., 1904, No. 13, p. 32o. 

< Menge, K.: Hand. d. Geschleohtskrankheiten, Vienna, 1910. 

' Wagner: Berlin, klin. Wochenschr., Berlin, December 25, 1911, No. 52. 

« Watson: Brit. Med. Jour., January 22, 1910. 


and salts. The solution thus obtained can be strengthened, by the 
addition of powdered lactic acid if deemed necessary. Watson first 
thoroughly cleanses the cervix and then applies the lactic-acid solu- 
tion. The treatment is administered daily. He reports excellent 
results from this treatment. Nassauer* strongly urges the dry treat- 
ment of cervical gonorrhea, and states that he utilizes this method in 
nearly all cases in which he formerly used tampons. He employs 
bolus alba because it is an impalpable powder and has a high absorptive 

Constitutional treatment is not usually required in gonorrheal 
cervicitis. The bowels should be regulated and general hj'gienic 
measures instituted. In the debilitated or anemic, tonics containing 
iron and strychnin are indicated. Von Franque- recommends that 
I mud-baths be taken twice a week. It is especially important that 
these patients be kept in bed during the menstrual periods. If this 
is found to be impossible, they should be confined to their rooms and 
all unnecessary exercise be interdicted; all forms of local treatment 
should be discontinued, and every effort be made to prevent the disease 
from spreading to the body of the uterus. 

Gonorrheal cervicitis is often extremely intractable, and persists 
despite all palliative measures that may be adopted. If this is found 
to be the case, trachelectomy will have to be resorted to. Amputa- 
tion of the cervix offers the best hope of cure in those cases in which 
palliative methods fail to produce satisfactory results after a fair trial. 
Hunner' recommends the destruction of the cervical glands by the 
actual cautery. The method he employs is suitable for office use, and 
does not require the administration of an anesthetic. His technic 
is as follows: With the patient in the dorsal position, a broad-bladed 
Sims' speculum is introduced and the anterior lip of the cervix grasped 
with a tenaculum and pulled down as far as possible. The nurse or 
a.ssistant stands at hand with the heated cautery. On handing the 
cautery to the operator the assistant continues to work the bulb with 
one hand, while with the other she retracts the s])eculum. The 
operator steadies the cervix with the tenaculum ami manages the 
cautery with the other hand. The strokes should l)e made one at a 
time, the cautery Ix'ing removed from the vagina after each ai)plication, 
as the patient feels the radiated heat on the vaginal walls. The 
l)atient should be warned that she will feel the heat, but must be told 
not to move, as there w ill be no pain. An exceiilioii to this rule is found 

' Ni'.-suucr: Miinch. mod. Wochcnschr., 1912, No. Id iml 11. 

= Vim I'ninipi.-; ('entrall)l. f. (lyn., HtOfi, No. :«. 

' lluiiMcr: .lour, .\iiicr. .Mid. As.sor., .Jiiniiiuy 20, HHHl, p. I'.M. 


in those patients who are suffering from a painful cervical scar. Wlaen 
this condition is present, Hunner advises a preliminary application 
of 20 per cent, cocain solution. Five or six strokes are made at each 
sitting. The strokes are radiating, and are from 2 to 5 mm. in depth, 
and vary in length according to the case. Treatments are given once 
in three weeks. Occasionally slight bleeding follows the treatment, 
and as a precautionary measure, a strip of gauze may be left in the 
vagina for twenty-four hours following the cauterization. Discharge 
is usually profuse for a few days following the treatment. An aver- 
age of ten treatments are required. 

Schindler^ believes that the uterus possesses a definite rhythmic 
automatic movement not influenced by the central nervous system, 
and that this action accounts for many of the endometrial and 
adnexal gonorrheal infections. His conclusions are based upon an 
extensive series of experiments which he has reported in detail. 
Atropin has been found to paralyze these movements. He therefore 
recommends that this drug be administered in the acute stage of 
gonorrheal infections, and at such times as extension upward is likely 
to take place, as, for example, after the emptying of a pregnant uterus 
in a patient known to have a cervical gonorrhea. Drenkhahn- also 
employs this drug in puerperal cases. Schindler' has employed 
atropin extensively in a large series of acute gonorrheal lesions, and 
has never observed any ill effects following its use, and beheves that 
it is of great benefit to such patients. 

Itching or burning of the external genitalia may occasionally be 
secondary to gonorrhea of the upper genital tract, producing a profuse 
discharge. Mild degrees of pruritus vuIvje are by no means infre- 
quent, especially in neglected cases, and in children may lead to mas- 
turbation. The author has never seen any very severe cases of this 
condition that were due to gonorrhea alone. Sanger* believes them 
infrequent. When the discharge is checked, the condition rapidly 
disappears, and the only treatment usually necessary is that directed 
to the primary gonorrhea and the accompanying vulvitis. When the 
itching or burning is extreme, a temporary application of phenol and 
menthol, of each, 10 grains to the ounce, or 50 per cent, turpentine 
ointment, may be employed until the discharge is checked. Clean- 
liness is essential. 

'Schindler, C: Arch. f. Gjni., Borlin, 1900, vol. Ixxxvii. p. 007; also Berlin, klin. 
Woch., 1909, vol. xlvi, p. 1691. 

- Drenkhahn: Therap. Monatsh., Felinuiry, 1905. 

» Schindler, C; Loc. cil. * Siinger: Cent. f. Gynak., 1894, p. 154. 



Winter and Ruge' refer to condylomata of the cervix; tlie condition 
is, however, extremely rare. Until 1900 Cullen- had only observed one 
case, and this was associated with tuberculosis. The tumors occur most 
frequently during pregnancy, and resemble condylomata of the ex- 
ternal genitalia or vagina. They vary in shape and are often pedun- 
culated. They are usually secondary to cervical gonorrhea. On 
account of the rarity of condylomata of the cervix, all tumors spring- 
ing from this location, and especially those that present a cauliflower- 
hke appearance, should be subjected to histologic examination in 
order to exclude the possibility of cancer. Venereal warts of this 
area may be excised and the wound closed with interrupted catgut 

' Winter and Ruge: Gynecological Diagnosis. 
2 Cullen: Cancer of the Uterus, 1900, p. 191. 




Strictly speaking, endometritis may be either cervical or corporeal. 
Although both forms of the disease may be set up by the same micro- 
organism, the pathology, symptoms, prognosis, and treatment are 
totally dissiiTiilar. In a preceding chapter we dealt with gonorrheal 
inflammations of the cervix, and in order to avoid confusion these 
conditions were designated cervicitis and endocervicitis, in contra- 
distinction to the term endometritis, which is here reserved for an 
inflammation of the corporeal endometrium. 

The name endometritis was formerly used to cover practically 
all endometrial diseases except actual tumor formation. This led to 
much confusion and to many unnecessary and often actually harm- 
ful operations. Much of this confusion doubtless arose as the result 
of the indiscriminate histologic diagnosis made upon specimens 
secured by curetage, such as glandular, interstitial, fungoid, hy- 
perplastic, or atrophic endometritis. Such diagnoses were usually 
based upon a , misconception of the normal histology of the en- 
dometrium. Since the excellent monograph of Adler and Hitsch- 
mann,' whose findings were confirmed by Keene- and the author, 
a clearer understanding' of the histology of the normal endometrium 
has resulted. It is now known that the changes in the endome- 
trium run in a definite cycle, the details of which have been 
described under the Pathology of Endometritis. It is sufficient for 
present purposes to state that the mucosa removed shortly before a 
menstrual period will be found to be thick and present all the appear- 
ances of what was formerly frequently incorrectly designated as 
glandular or hyperplastic endometritis, whereas the post-menstrual 
endometrium will be found to be thin and of the type often spoken 
of as atrophic or interstitial endometritis. Another cause for con- 
fusion has been the application of the term endometritis to such 
endometria as are thickened or altered as a result of variations in 
the blood-supply and from causes other than actual inflammation. 

' Adler and Hitsclimann: Monats. f. Geb. u. Gyn., 1908, vol. xxvii, No. 1. 
= Xorris, C. C, and Kcene, F. E.: Surg., Gyn., and Obstet., January, 1909, p. -14. 


The general trend at present is to view all forms of endometritis as the 
products of bacterial infection, and in this opinion the author concurs. 
When, therefore, the term endometritis is used here, it will be intended 
to designate a condition induced by the direct action of bacteria. or 
their toxic products upon the endometrium. As a result of our more 
accurate knowledge of the histology of the endometrium, we now recog- 
nize that inflammation of this structure, instead of being extremely 
frequent, as was formerly believed, is actually of comparative rarity. 
This is particularly true of the gonorrheal conditions unassociated 
with tubal inflammation. 

Gonorrheal endometritis is always the result of an ascending in- 
fection, the cervix being invariably previously attacked. From the 
endometrium the disease may and often does spread to the tubes, 
where it produces the various inflammatory lesions of the adnexa. 
In the histologic examination of many endometria from cases of 
pyosalpinx the mucosa of the uterus was found to be normal in a con- 
siderable proportion of specimens, thus leading to the belief that in a 
certain percentage of cases gonorrhea in this locality undergoes spon- 
taneous cure, although Bumm' and others have proved that the 
gonococci may in some instances lie dormant without setting up an 
inflammatory reaction. This Jatter explanation is doubtless the 
c(jrrect one in many cases. It seems probable that the resolution 
of the endometrium depends largely upon the perpendicular arrange- 
ment of the uterine cavity, which favors drainage, and the abun- 
dant blood-supply of the mucous membrane. Active inflammation 
of the endometrium is not infrecjuently kept up in cases of pyosalpinx 
by the leakage of pus through the intramural portion of the tube into 
the uterine cavity. 

The actual fre(iuency of endometritis is shown l)y the fact that 
in the Laboratory of Clj-necologic Pathology at the University of Penn- 
sylvania, the author has examined 995 endometria removed for 
various conditions, and ainong this number he found only 20S cases 
of endometritis, 12 being of puerperal origin, whereas 14 were 
tui)ercular. Of the 194 cases (tubercular cases excluded), including 
those of puerperal origin, 121, or ()2.3() per cent., were, judging from the 
clinical symptoms, gonorrheal in origin. Of the 12 puerperal cases, 
ti were associated with the presence of, and were probably caused by, 
the gonococcus. All the cases examined have not been subjected to 
bacteriologic tests, so that it is impossible to state positively the pro- 
portion of these infections that were of gonorrheal origin. Almost 
similar results regarding the frequency of endometritis are reported 

' Uiinim: Vril's Il.uiil. ilcr ( ivii. 


by CuUen, who states that during a period of four years in the Gyneco- 
logic Laboratory of the Johns Hopkins Hospital, there were only 48 
cases of endometritis, or an average of one a month. When we con- 
sider that neither of these reports refers exclusively to gonorrheal con- 
ditions, the comparative infrequency of this type of infection of the 
endometrium is at once apparent. Of the 194 cases of endometritis 
previously referred to, 101 were associated with more or less involve- 
ment of the uterine musculature. Metritis must, therefore, be re- 
garded as a frequent accompaniment of endometritis. Of the 141 
cases of endometritis that were associated with inflammatory lesions 
of the tubes, and which, it seems fair to assume, may, at least in the 
large majority of cases, be considered of gonococcal origin, 71 were 
complicated by metritis. It is important to bear in mind the relative 
infrequency of endometritis compared with cervicitis, and the associa- 
tion of the former with metritis and often with adnexal lesions, in 
considering the treatment of this condition. In previous years a 
lack of knowledge of this point led to the indiscriminate emploj^ment 
of intra-uterine applications and the performance of curetments, 
which have often been followed by the most disastrous results in 
cases in which the source of the trouble really lay in the cervix. Leip- 
mann^ states that about 50 per cent, of the cervical gonorrheas 
eventually extend above the internal os. In the large series of cases 
reported upon by the Committee of Seven- invasion of the uterine 
cavity and adnexa had occurred in 40 per cent, of patients. Opitz' 
believes that not more than 10 per cent, of gonorrheas extend above 
the internal os. 

Gonorrheal endometritis may be either acute or chronic, and 
varies in severity quite markedly in different cases. Chronic endo- 
metritis may result from an acute attack or may be practically subacute 
or chronic from the onset. 

Acute Gonorrheal Endometritis 
Symptoms. — The disease usually makes itself manifest shortly 
following a labor, miscarriage, or abortion, or just after a menstrual 
period. In some cases the infection of the endometrium occurs during 
menstruation, in which event an abrupt cessation of the flow may 
take place or the period may be prolonged or profuse. At the men- 
strual periods, and following the emptying of a pregnant uterus, the 
cervix is softened, the canal unusually patulous, and the plug of 
cervical mucus less occlusive, conditions that favor extension of the 

' Loipmann: Monats. f. Hautkrankh., 1904, vol. i. 

= Med. News, Decenibor 2. 1909. ' Opitz, E.: Medizinische Klinik, .January S, 1911. 


infection from below. In former years, when intra-uterine office 
manipulations and treatment were in general vogue, infection fre- 
quently resulted from such procedures by carrying infection from the 
cervix to the body of the uterus. Cameron' states that endometritis 
is likeh' to follow extra-uterine pregnancy. As the uterus during 
extra-uterine gestation undergoes, although to a lesser extent, many 
of the changes common to normal pregnancy, such as slight enlarge- 
ment, slight .softening of the cervix, etc., the etiologic relationship 
between the two concUtions can easily be understood. In acute 
gonorrheal endometritis constitutional symptoms are, as a rule, 
present. The condition is sometimes ushered in by a chill, which is 
not often severe. Pyrexia is almost invariably present, although the 
temperature rarely rises above 101.5° F. The pulse ranges from 100 
to 115, and the frequency of respiration is usually correspondingly 
increased. The concomitant symptoms of fever are present. Nausea 
and vomiting may occur, especially if the infection is a severe one. 
Diarrhea and rectal or vesical tenesmus may be present. Pain is not 
marked, but is nearly always complained of over the lower abdomen, 
chiefly in the region of the uterus. If the acute attack occurs during 
a menstrual period, irregularities are frequently observed, these 
usually taking the form of an excessive flow. The leukorrhea, which 
at the very onset may be diminislw^d, soon becomes profuse^ The 
discharge coming from the endometrium can be distinguished from 
that originating in the cervix by its thinness and the lack of the tena- 
cious, glairy mucus that is so characteristic of the cervical secretion. 
-As cervical gonorrhea is almost invariably an accompaniment of 
endometritis, the discharge from the body of the uterus and from the 
cervix are usually intimately mixed. In such cases the discharge is 
often very profuse, mucopurulent, or purulent in character, and in 
grave cases it is sometimes l)l()od streaked. It is made up of mucus, 
serum, epithelial debris, and pus, and contains typical gonococci, 
which, during the acute stage, can usually l)e demonstrated without 
difficulty. At this stage a pelvic examination will disclose the fact 
that the uterus is sliglitly enlarged, uniformly softened, and tender, 
and the cervix hypertrophied and the canal more patulous than normal. 
Evidences of gonorrhea in the urethra or external genitalia are nearly 
always present, and gonococci may sometimes be recovered from these 
locations when their tlemonstration in the uterine discharge, by the 
ordinary methods, is difficult or impossible. Owing to the mixture 
of the cervical and corporeal discharges, but little dependence can be 
placed upon the demonstration of gonococci in the leukorrhea, unless 

' Cameron: Brit. Mi.l .lour., VMV.K vol. ii, p. lO'JS. 


the material for examination is secured directly from the body of the 
uterus, a procedure that in most cases is hazardous. 

Diagnosis. — Acute gonorrheal endometritis is to be differentiated 
from septic endometritis, the. typical variety of which is produced by 
the streptococcus. The latter almost invariably follows as the result of 
contamination of the uterine cavity by manipulations, and is usually 
preceded by labor or iniscarriage. Gonorrheal endometritis may be 
further distinguished from the septic form of the disease by the 
milder and more chronic symptoms of the former, the concomitant 
evidences of gonorrhea in other portions of the genital tract, by the 
presence of the specific microorganisms in the exudates, and by the 
tendency of the gonorrheal form to become chronic. Acute gonorrheal 
endometritis frequently extends to the tubes, but the positive diag- 
nosis of this complication during the acute stage is often difficult. 
The points that would suggest a spread of the infection to the adnexa 
are extension of pain to the ovarian regions, severity and persistence 
of the symptoms, and the demonstration, by vaginal examination, of 
enlarged and tender tubal lesions. If a bimanual examination is 
performed at this stage, it should be carried out with the utmost 
gentleness, because of the danger of spreading the infection. Indura- 
tion in the vaginal fornices, fixation of the cervix, and marked tender- 
ness in these areas are signs indicative of an extension of the disease 
beyond the uterus. Small intra-uterine tumors, especially if they 
are undergoing degenerative changes, sometimes produce subjective 
symptoms similar to acute gonorrheal endometritis. Their differ- 
ential diagnosis is, however, usually easy. 

Treatment. — The treatment of acute gonorrheal endometritis 
is mainly expectant. The patient should be confined to bed. The 
bowels should be regulated by the use of mild cathartics and an 
occasional dose of the salines. The diet should be regulated, and 
should include the drinking of plenty of water. To aid drainage of 
the uterine cavity the patient may with advantage be placed in the 
upright Fowler position. If this is found to cause much discomfort, 
the position may be assumed for half an hour two or three times a day. 
The posture should be somewhat modified in the individual case 
according to the position of the uterus. Thus if the uterus is in ante- 
position, the extreme upright posture will not give so good drainage 
as if the patient is inclined slightly backward, while if the uterus is in 
retroposition, the perpendicular or the Sims left lateral posture is the 
most beneficial. No special medication by mouth is usually required. 
If the constitutional symptoms are marked or shock is present, stimu- 
lating treatment may be indicated. This, however, is not the rule. 



as such symptoms are indicative of a streptococcic rather than of a 
gonococcal infection. If the temperature is high, cold sponges may be 

To relieve the pain and to hasten the subsidence of the inflamma- 
tion ice-bags or ice-coils maj^ be applied over the lower abdomen. In 
some cases the application of heat in the form of turpentine stupes or 
large poultices is preferable. Whichever method gives the greatest 
comfort to the individual patient is the one to be adopted. The ex- 
ternal genitalia should be kept clean by the use of irrigations of weak 
antiseptic solutions, such as those previously directed in the treat- 
ment of vulvitis. If the discharge is profuse, cleansing vaginal irriga- 
tions of physiologic normal salt solution of a temperature of about 
110° F. should be employed once or twice daily. During the early 
stages, or when the cervical canal may be widely open, the douches 
are best administered with the patient in Fowler's position, great care 
being exercised not to drive the fluid forcibly into the vagina for fear 
of washing the vaginal discharge into the uterine cavity. If any 
doubt exists as to the possibility of confining the irrigations to the 
vagina, douches had best be omitted at this stage. The chief in- 
dication is to keep the vagina clean. A sterile vulvar pad should be 
appUed. All soiled dressings should be burned, and the precautionary 
measures recommended for the treatment of acute gonorrhea of the 
external genitalia should be instituted. Under this plan of treatment 
the acute symptoms usually subside in from five days to a week. 

Chronic Gonorrheal Endometritis 

This condition may occur as a se(iuela of an acute process, or may 
originate as a subacute attack. Like acute gonorrheal endometritis, 
the disease is always associated with gonorrhea of the cervix. Acute 
exacerbations may occur at any time, but are most frequent after 
abortion, miscarriage, labor, or at the menstrual periods, or the at- 
tacks may follow improperly applied intra-uterine manipulations or 
rough pelvic examinations. 

Symptoms. — The chief symptom of chronic gonorrheal endome- 
tritis is the persistent leukorrhea. The discharge is less in amount 
and not so purulent as in the acute condition. At this stage of the 
disease it is often extremely difficult to distinguish between the dis- 
charge of a cervicitis and that of an endometritis. In the latter con- 
dition the discharge; is whitish or yellowish in color, and thiiuun- than 
that originating in the cervix, although, as a rule, the discharges are 
intimately mixed. Microscopic examination of tiie secretion shows 
lliat it is composed of serum, epithelial debris, leukocytes, and oc- 


casionally a few red blood-corpuscles. According to Adler and 
Hitschmann/ and Norris and Keene,'- normally no mucus is se- 
creted by the endometrium except near the menstrual periods; 
any mucus that is present, therefore, is mainly of cervical origin. 
It is often only after repeated search that gonococci can be detected 
in the discharge. This is due not only to their scarcity in number, 
but also to the fact that the specific microorganisms are sometimes 
atypical in their morphology and staining properties in long-stand- 
ing chronic cases. The demonstration of the gonococcus is useless 
so far as the diagnosis of an endometritis is concerned, as the mi- 
croorganisms may have come from the cervix, as a result of an ad- 
mixture of secretion from that locality. This, of course, does not 
apply to secretions obtained directly from the uterine cavity, but 
as the dangers of indiscriminate intra-uterine manipulations are so 
great, this test is of little practical value. 

As a result of chronic gonorrheal endometritis menstrual disturb- 
ances, such as amenorrhea, menorrhagia, and metrorrhagia, are not 
infrequent. Irregularities as to date of the appearance of the flow 
and profuse menstruation are the most frequent manifestations. 
Dysmenorrhea is a common symptom and is usually of the conges- 
tive type, persisting throughout the first few days of menstrua- 
tion. Occurring in women in whom menstruation has previously 
been painless, and in the absence of other gross lesions, and espe- 
cially if gonorrhea of other portions of the genital tract exists, dys- 
menorrhea is a most suggestive symptom. Gonorrheal endometritis 
produces sterility, but exceptions to this rule are not infrequent. 
In those cases in which impregnation does take place, abortion 
often results. A pelvic examination of these cases reveals evidences 
of gonorrhea in the external genitalia or cervix, and in some cases, 
also, a slight enlargement and softening of the uterus may be de- 
tected. The enlargement and change in consistence of the uterus are 
dependent upon the degree of metritis that accompanies the endo- 
metritis, and are not usually sufficiently pronounced to be of much 
practical value as a diagnostic sign. 

Diagnosis. — As will be observed from a review of the symptoms, 
the diagnosis of chronic gonorrheal endometritis is not easily made, 
the chief difficulty lying in differentiating between a cervical gonorrhea 
and a cervicitis combined with an endometritis. In attempting the 
differentiation, the frequency of cervical infection and the relative 
infrequency of cervicitis combined with endometritis without adnexal 

' Adlor and Hitschinann: Monats. f. Geb. ii. Gyn., vol. xxvii, No. 1. 

- Norris, C. C, and Keene, F.: Surg., Gyn., and, January, 1909, p. 44. 


involvement, should be borne in mind. When chronic gonorrheal 
endometritis is present, it is often associated with inflammations of 
the tubes, and only by careful pelvic examination can these complica- 
tions be excluded. 

Treatment. — Excessive exercise should be interdicted, and in 
some cases a course of treatment while the patient is confined to bed 
will be found beneficial. Rest should be especially enjoined for a few 
days previous to, during, and following the menstrual period, for, as 
has been stated, it is at this time that exacerbations and extension 
of the infection are especially likely to take place. The bowels should 
be regulated, and a nutritious and easily assimilated diet prescribed. 
If the patient is anemic, iron is indicated, and in debilitated subjects 
an endeavor should be made to build up the general health. Hot 
sitz-baths of salt water, given at night, are often of benefit, and are 
especially valuable in relieving the congestive pelvic pain that fre- 
quently precedes menstruation. Webster^ recommends counter- 
irritation by means of blisters over the iliac regions. As regards local 
treatment, opinions vary widely. Formerly, intra-uterine applica- 
tions were generally employed in office practice, and undoubtedly 
in many cases resulted in spreading the disease. Not only is there 
danger of mistaking a gonorrheal cervicitis for an endometritis and 
thus carrying infection to a previously normal uterine cavity, but 
even if the diagnosis is correct, there is considerable danger of caus- 
ing an extension of the disease to the tubes. Another objection 
that may be made to this treatment is that a preexisting salpingitis 
may be overlooked and an acute attack of pelvic p(>ritonitis thus pre- 

In a small proportion of jiaticnts the diagnosis of certain types 
of tubal lesions is extremely difficult, if not impossible, without the 
aid of an anesthetic. This proportion is doubtless small, but in the 
treatment of a large series of cases it constitutes a very grave objection 
to the ordinary routine method of making intra-uterine applications 
as gene-rally performed in office practice. Such intra-uterine applica- 
tions are painful and do no good. Emmet was one of the pionc(>rs in 
pointing out the limited field of usefulness of intra-uterine applica- 
tions as generally made. For these reasons, therefore, the author 
considers that intra-uterine applications or manipulations should 
not be performed in these cases unless the technic demanded by a 
major vaginal operation can be strictly carried out. This is usually 
impossible in oflice treatment and without the aid of an anesthetic. 
If, after a course of hot fomentations and vaginal (h)uches extending 
over a jjcriod of at least six weeks, together with the local treatment 
' Wi'listcr; Diseases of VVomcn. 


already indicated for gonorrhea of the cervix, the symptoms still 
point to an intra-utcrine infection and show no signs of abating, the 
patient should be anesthetized and, after a careful pelvic examination 
has been made to exclude the possibility of adnexal complications, 
a thorough dilatation and curetage of the uterus and cervix, under 
strict antiseptic and aseptic precautions, should be performed. The 
cervix should be widely dilated in order to facilitate the intra-uterine 
manipulations. The endometrium of the sides of the uterus, should 
be removed with a small Sims sharp curet, followed by a Recamier 
curet for the fundus and the portions about the tubal openings. The 
curetage should be done thoroughly and systematically, and every ef- 
fort made to remove as much of the mucosa as possible. Clark has 
shown that it is impossible to scrape away the entire endometrium, es- 
pecially that situated in the tubal angles and the deeper portions of the 
glands which sometimes penetrate the uterine musculature. Never- 
theless, the gonococcus, being chiefly a surface microorganism, dezymo- 
tization of the uterine cavity can be accomplished in large measure. 
Following the curetage the uterine cavity should be wiped dry with 
strips of gauze. This will remove anj^ debris that may have been 
left in the uterine cavity. It is not advisalsle to employ irrigation 
because of the danger of washing microorganisms from the uterine 
cavity into the tubes and thus spreading the infection. This is 
especially likely to occur in puerperal cases, or in those in which a 
metritis is present. Under such circumstances the uterine ostia of 
the Fallopian tubes may be relaxed in the general muscular relaxation 
of the uterus. The uterine cavity should then be painted with a 
strong solution of one of the antiblennorrhagics. For this purpose 
perhaps the best is the tincture of iodin. Polak strongly recommends 
iodin for all gonorrheal conditions, and in the author's hands it has 
given excellent results. It is important to have the tissue as dry as 
possible before applying the iodin. A strip of gauze saturated with 
the medicament should then be inserted into the uterine cavity and 
left in place for six hours. Bovee^ states that curetage may be per- 
formed with impunity if thorough application of the full strength of 
tincture of iodin is applied efficiently and promptly to the endometrium, 
avoiding too much dilution by blood and serum. The danger of light- \ 
ing up the latent infection in the endometrium by the curetage and I 
iodinization and thereby subjecting the previously healthy tubes to the I 
danger of infection is practically nil. Unless followed by the applica- 
tion of a gonococcid, curetage should never be performed. Boldt^- 
prefers to irrigate the uterus after the curetage, and follows this h-;m 

' Bovee, J. W.: Amer. Jour. Obst., July, 1911, p. 101. 

■ Boldt: Jour. Amer. Med. Assoc, February 1, 1908, p. 332. 


packing the uterine cavity with gauze saturated with protargol solution. 
He removes the gauze in twentj^-four hours and repeats the irrigation 
and tamponade on the third day. This is said not to cause much in- 
convenience to the patient if the cervical dilatation has been sufficiently 
effectual. Tweedy^ follows the curetage by the application of 33 per 
cent, formahn solution, and leaves a gauze drain saturated in this 
solution in the uterine cavity for twenty-four hours. Prowe- follows 
the curetage by uterine tamponade of gauze soaked in pure ichthyol. 
Other authorities prefer applications of strong solution of silver nitrate 
or even pure phenol. If the latter is employed, its use should im- 
mediately be followed by an application of 95 per cent, alcohol. 
Following the operation the patient should be kept in bed for a week. 
For the first twenty-four hours it is preferable, for purposes of drain- 
age, to have the patient in the Fowler position. Subsequently this 
posture should be assumed for one-half hour three or four times daily. 
Twenty-four hours after removal of the uterine gauze vaginal irriga- 
tions of some weak antiseptic solution, such as the A. B. C. douche, 
should be given and repeated two or three times daily. On the second 
and third day following the operation the discharge is usually profuse. 
After each defecation or urination the external genitalia should be 
irrigated with an antiseptic solution, and the vulva should be pro- 
tected by sterile pads as long as the patient remains in bed or the 
discharge continues. Litiuid food should be given for the first twenty- 
four hours following the operation, after which time a rapid return 
to full diet may be made. Little morbidity attends the operation of 
curetage if it is performed under proper aseptic conditions. The 
' chief danger is the risk of setting up of a pelvic peritonitis through an 
extension of inflammation. When this occurs, it is usually the result 
of a preexisting adnexal lesion that has been overlooked. When 
the cervix is badly diseased and in cases that have resisted palliative 
treatment, the curetage may be combined with a trachelectomy. In 
all cases the curetage should include a thorough scraping of tlie cer- 
vical canal with a sharji curet of the Volkmann type, and the free 
application of the germicidal solution to this area. It is hardly 
necessary to state that before the introduction of strong antiseptic 
solutions into the uterine cavity the vagina should he carefully pro- 
tected by gauze or sterile vaselin. .V time — four to five days — be- 
fore an expected menstrual period should be selected for the curetage, 
as at this period the endometrium is thicker and softer and can be 
more thoroughly removed. 

' Twee<ly: Brit. .Med. .Four., vol. ii, p. lO'JS. 

U'rowc: IJcrliii. kliii. WcMlii'ii.sclir., NovciiiIkt 11, I'JlO. 


The dangers of curetage in those cases comphcated bj^ tubal 
or adnexal lesions have previously been dwelt upon. This, how- 
ever, does not apply to uterine treatments that are performed in 
conjunction with operations on the appendages. The after-treat- 
ment of cases in which curetage has been performed should consist 
of cleansing douches, and for a period of at least one month only 
the mildest forms of exercise should be indulged in. IVIenstruation 
is often somewhat irregular and profuse for one or two periods fol- 
lowing the operation, and patients should remain in bed as long as 
the flow continues. For the treatment of menorrhagia Boldt^ recom- 
mends the internal administration of cotarnin hydrochlorid, given 
in doses of three grains, in gelatin capsules, three times daily. Ergot, 
hydrastin, and viburnum prunifolium, or combinations of the three 
drugs, may also be employed. Douching should be omitted during 
menstruation. Coitus should not be indulged in until the disease 
has been eradicated, and precautionary measures, such as have been 
recommended in the treatment of gonori-hea of the external genitalia, 
should be instituted. 

When the plan of treatment just outlined fails to effect a cure 
and it is certain that an endometritis exists, it may be found advisable 
to repeat the operation. This should not, however, be done until at 
least three months have been allowed to elapse. The histologic 
examination of the curetings obtained at the first operation will afford 
confirmatory evidence of a previously existing endometritis. The 
demonstratioij of gonococci in the endometrium in chronic cases 
of gonorrheal endometritis is difficult, and little importance can be 
attached to negative findings. In a few cases, after the operation, 
more or less profuse uterine bleeding and other sjmiptoms of en- 
dometritis will persist, despite the treatment just descril^ed. In 
these cases, if the cervical canal is already dilated, intra-uterine 
applications, performed under the strictest aseptic precautions, are 
justifial)le and sometimes beneficial. The contraindications to this 
plan of treatment are a history or symptoms pointing to inflam- 
matory lesions of the adnexa, doubt as to the existence of an en- 
dometritis, or the presence of a tightly contracted cervical canal. 
A period shortly after the cessation of menstruation should be se- 
lected, as at this time the endometrium is thin and applications 
can, therefore, be expected to reach the deeper glands better than 
at any other time. The patients should be placed in the dorsal 
position, and the external genitalia and vagina thoroughly scrubbed 
with tincture of green soap and hot water, followed by a 1 : 2000 bi- 

1 Boldt: Jour. Amer. Med. Assoc, February 1, 190S, p. 332. 



chloric! solution. If the green soap and water do not remove the 
cervical mucus, the cer\dx should be sprayed and swabbed with one 
of the alkaline solutions recommended in the treatment of cer\ical 
gonorrhea, and the soap and water again applied. The vagina should 
now be packed with gauze or cotton soaked in the bichlorid solution. 
This should be left in place while the operator makes the other neces- 
sary preparations. Then, under strict aseptic precautions, the cervix 
should be exposed through a large bivalve speculum, and the anterior 
lips grasped in a double tenaculum. Cotton pledgets or sterile vaselin 
are now placed in the vagina, to protect it from the action of the anti- 
septic that is to be employed. Tlije applicators, which should have 
been previoush' prepared and wrapped with a thin layer of sterile 
cotton, are now dipped in the solution and applied. For this purpose, 
tincture of iodin is perhaps the most efficient drug, although formalde- 
hyd (37-40 per cent.), silver nitrate (1 dram to the ounce), pure ich- 
thyol, or pure phenol are preferred by some operators. The solu- 
tion should be applied thoroughly to all parts of the uterine cavity, 
and especially to the tubal angles. If phenol is the chosen medica- 
ment, its use should be followed by the application of 95 per cent, 
alcohol. It is necessarj', as has been stated, that the solution employed 
reach all parts of the uterine cavity, and to attain this end it is ad- 
visable to prepare three or four applicators before beginning the 
treatment, so that they may be used quickly, one after the other, 
without the delay occasioned if only one applicator is at hand. If 
iodin is the antiseptic selected, an excellent plan is to precede the 
use of the applicators by the injection of a dram of the solution by 
means of an intra-uterine applicating syringe, and follow this im- 
mediately by the insertion of cotton pledgets soaked in the same 
solution. The applications cause considerable pain, and for this 
reason it is necessary to complete the treatment quickly after the 
antiseptic is once applied, or the patient is likely to draw up on the 
table and make the remainder of the procedure difficult. The treat- 
ment should be concluded by introducing a sterile vaginal tampon 
saturated with boroglycerol or boric-acid ointment and the applica- 
tion of a sterile vulvar dressing. The pain caused by the intra-uterine 
application, as outlined above, lasts for but a few hours, and if un- 
usually severe, may be alleviated by the administration of an anodyne. 
If the patient is of a nervous temperament, the pain may be tempo- 
rarily relieved and the application facihtated by cocainizing the uterine 
cavity prior to the application. 

The patient should remain quiet for three or four days following 
the troatnicut. She should be warned that the vaginal discharge 


will probably be temporarily increased. As has previously been 
stated, it is important that husbands of such patients be made ac- 
quainted with the dangers of reinfection, and that cohabitation be 
interdicted until both husband and wife are absolutely cured. If 
it is found impossible to attain this end, precautionary measures 
should be adopted, and coitus enjoined for at least a week following 
the cessation of menstruation. For these cases, Dudley^ has sug- 
gested an ingenious form of treatment. The device used is a tupelo 
sponge or sea-tangle tent, over the distal end of which has been at- 
tached half a gelatin capsule filled with whatever medicament may be 
selected for intra-uterine application. For cases of endometritis or 
metritis this observer recommends a powder consisting of one part 
of iodin crystals and two parts of potassium iodid, this being a pro- 
portion that dissolves readily in water. From two to four grains 
of this mixture are introduced at each treatment. The tent is steril- 
ized by dry heat, and the gelatin capsule by the iodin, which is al- 
lowed to remain in the capsule for two days before it is used. The 
technic of the application is as follows: The vagina and external 
genitalia are cleansed as for an ordinary plastic operation. No general 
anesthetic is required. An applicator saturated with a 10 per cent, 
solution of cocain is introduced into the uterus and allowed to re- 
main in place for ten minutes. The cervix is then carefully dilated 
with a small Goodell dilator and the tent introduced. In about 
twelve hours the tent is removed, and, if it is thought advisable, a larger 
one may now be inserted. The advantages claimed for this method 
of treatment are that good dilatation is secured and the medication 
is applied to the endometrium for a prolonged period. Dudley rec- 
ommends that the treatment be carried out in a hospital. 

Intra-uterine applications in office practice have a limited field 
of usefulness, and the benefits to be derived from this plan of treat- 
ment are not, as a rule, great. The author does not, however, go so 
far as Boldt,^ who stigmatizes intra-uterine treatment performed in 
office practice as "tinkering," but believes that the contraindications 
to such treatment should be rigidly adhered to, and that in all cases 
operative intervention, of the type described, will give far better 
results. Concomitant gonorrhea of the cervix, urethra, or external 
genitalia should receive appropriate treatment. 

Vaporization has been employed by some operators in the treat- 
ment of chronic gonorrheal endometritis, with good results. The 
introduction of live steam into, the uterine cavity is not without danger. 

' Dudley, E. C: Jour. Amer. Med. Assoc., June 24, 1911, p. 1S74. 
^ Boldt: Jour. Amer. Med. Assoc, February 1, 190S, p. 332. 


^lany cases have been reported in which the uterine cavity has been 
accidentally obliterated, or in which adhesions between the anterior 
and posterior uterine walls have formed as a result. It is claimed for 
this treatment that it is applicable to all cases; that it is free from 
the danger of spreading infection, and that it is more thorough than 
curetage and the application of germicides. That vaporization is 
free from the danger of spreading infection has not been proved; in 
fact, the author believes that the risks attending this plan of treatment 
are quite as great as, if not greater than, those following curetage; he 
does not beheve that the treatment is more thorough than that al- 
ready described, as it is self-evident that it is impossible to remove 
all the endometrium without causing obliteration of the uterine cavity. 
One of the chief disadvantages to vaporization is the difficulty of 
accurately controlling the stream and ascertaining the exact depth 
to which the tissues are being destroyed. The endometrium in these 
cases varies quite markedly in thickness, and what would be sufficient 
steam completely to boil off the mucosa in one case, might only destroy 
the superficial layers in another. 

Brindeau' has found the use of cviltures of the lactic-acid bacillus 
of great value in various gj'necologic conditions in which irritating 
discharges and inflammatory conditions are present. He has treated 
by this method 14 cases of endometritis and 78 additional patients 
suffering from various complaints. In endometritis the treatment 
is said quickly to overcome the offensive nature of the discharge. 

Adenomyoha of the Uterus wriH Chronic Gonorrheal Endometritis 
Adenoniyoma of the uterus is u (•omi)aratively frequent tumor. 
According to the statistics from the Laboratory of Gynecologic Pathol- 
ogy at the University of Pennsylvania, in a series of 395 myomatous 
uteri this tumor has been found 24 times, or in 6.7 per cent, of all cases. 
According to C'ullcn,- adenomyomata are found to constitute about 
5.7 per cent, of all myomata. ("ullen has shown that, in a large per- 
centage of cases, the tumors are an ingrowth of the normal eiulonie- 
triuni into the substance of either a discrete or a diffuse myomatous 
tuniiir: fnnii this it would naturallj' be concluded that the endome- 
trium in the neoplasms might be subject to an extension of inflam- 
mation from the uterine cavity, a fact that has been demonstrated 
in a few instances. The reason that the condition is not more fre- 
quently encountered is probably due to the fact that the gf)nococcus 
is mainly a surface microc'irganism, and that even in ordinary cases of 

' Hriiiilcim; Arch. mens, fl'ohsl. ct dc pyii., Miircli, 1!(12. 
'C'lilliii: AdciininyorriM of l[ic I'liTUs, l'.H)S, p. 1. 


endometritis the superficial portions of the mucosa are the areas 
chiefly involved. It would, therefore, follow as a matter of course 
that the deeper portions of the long glands and their surrounding 
stroma, which have grown far into the myomatous tissue, would be 
even less frequently diseased. Another factor that plays a part in 
the protection of adenomyoma from gonorrheal infection is that many 
of the glands in the tumor substance have been partially or completely 
cut off from the endometrial cavity by the constriction caused by the 
growth of the neoplasm, and are thus isolated from the source of the 
infection. Of the 24 cases of adenomyoma examined by the author, 
7 were associated with endometritis, and in only 1 of these were in- 
flammatory changes at all marked in the endometrial tissue of the 
tumor. All 7 cases of endometritis were accompanied Isy inflamma- 
tory lesions of the appendages. In the one specimen a moderate de- 
gree of inflammatory reaction was present in the mj^omatous tissue 
adjacent to the glands. The adenomyoma was of the diffuse t3^pe. 

The symptoms of endometritis occurring in and with an adenomy- 
oma of the uterus are those of uncomplicated adenomyoma of this 
organ, superimposed upon which are the evidences of an endometritis, 
as previously described. Beyond the diagnosis of an endometritis 
complicating a myomatous tumor of the uterus, probably adenomatous 
in character, a definite distinction as to the type of lesion present is 
impossible before the neoplasm has been subjected to a histologic 
examination. The treatment is, of course, operative, and should 
depend largely upon the individual case. 

Inflammation of the uterine musculatiu'e may be either acute or 
chronic in character. The condition may be general, invoh'ing the 
entire uterus, or may be localized to certain portions, as in the case of 
abscess formation. (Owing to the diversity in symptoms and to the 
rarity of the lesion, intramural uterine abscesses ^^dll be described 
under a separate heading.) 

Acute Gonorrheal Metritis 
Acute gonorrheal metritis is alwaj's accompanied bj' an endome- 
tritis. If the latter is severe, the underlying muscular structures are 
almost certain to be involved. Metritis is especially likely to occur 
if the endometritis follow childbirth or miscarriage : the soft, involut- 
ing uterus offers little resistance to the microorganisms, and makes an 
excellent nidus for infection. Madlener^ was one of the first observers 
to demonstrate the gonococcus in the uterine musculature. 
> Madleuer, M.: Cent. f. Gyn., 1895, No. 50. 


Symptoms. — These depend largely upon the grade of infection 
and the amount of resisting power of the individual. In the main, 
the symptoms are similar to those accompauA-ing acute eiidometritis, 
and which have been described elsewhere. AMien metritis is present, 
the severity of these symptoms is Ukely to be augmented. The con- 
stitutional effects are more severe, and the disease does not yield so 
readily to treatment. The condition is usually ushered in with a 
chill, followed by nausea, vomiting, malaise, chilliness, or headache. 
The pulse-rate is increased, the temperature is elevated, the tongue 
becomes coated, the appetite is lost, and constipation is usuallj^ present, 
although sometimes there is diarrhea. If lactation is present, the 
secretion of milk may be diminished or abolished. The discharge 
is increased in amount, and is frequently of a dark, chocolate color, 
owing to the admixture of blood, but it may be yellow or even whitish. 
The uterus is uniformly enlarged, and is tender to the touch. Tender- 
ness of the uterus and irregular and profuse menstruation are usually 
pronounced symptoms. Adnexal complications are more frequent 
than in uncompUcated endometritis. The cervix is invariably in- 
volved, and is usually the seat of a well-marked cervicitis. The 
cervical canal is generally markedly patulous and easily dilated. 

Diagnosis. — When acute gonorrheal metritis follows pregnancy or 
abortion, the condition must be distinguished from septic metritis 
caused by the streptococcus or other pyogenic microorganisms. In 
the latter type of infection the symptoms are, as a rule, more severe, 
the pulse and temperature are higher, the general constitutional 
symptoms are likely to be more alarming, and the condition comes on 
earlier. In the gonorrheal variety, on the other hand, during the 
first few days following the emptying of the uterus the gonococci 
multiply in the superficial layers of the endometrium, w^hereas in 
the deeper layers there is an outpouring of leukocytes, forming a 
protective barrier of resistance. During this period the symptoms 
arc not pronounced. 

The diagnosis of acute gonorrheal metritis maj' i)e made from the 
evidences of gonorrhea about the external genitalia, urethra, and 
cervix, and from the bacteriologic demonstration of the infecting 
micnxirganism from these locations or in the lochia. The diagnosis 
of gonorrhea in the external genitalia does not, of course, preclude the 
possibility of a streptococcic infection existing in the uterus, but is 
strong presumptive evidence of the type of infection present. Further- 
more, the gonococcus produces extension bj- way of the mucosa, 
so that if complications arise, the tubes are almost always affected, 
whereas if the infection is due to the streptococcus, cellulitis of the 


broad ligament, with its accompanying symptoms, is often found. 
In gonorrheal metritis, especially of it follows the puerperium, adnexal 
complications are the rule. "WTien following the emptying of a preg- 
nant uterus, gonorrheal metritis must also be distinguished from 
autointoxication from the bowels and from lesions in the breasts, con- 
ditions that will be more fully dealt with in the chapter on Gonorrhea 
in the Puerperium. 

Treatment. — This should be similar to that previously suggested 
for acute endometritis. As the constitutional symptoms are likely 
to be more severe, more active general treatment is indicated. If 
the uterus is large and boggy, the administration of ergot is often 
followed by good results, but the drug should not be employed if the 
presence of an abscess of the uterine parenchyma is suspected. The 
internal administration of atropin is said by Schindler^ to be beneficial 
as a prophylactic measure against the spread of the infection, and may 
be employed in all acute gonorrheal infections of the uterus, as de- 
scribed in a previous chapter. The drug is given in the ordinary 
therapeutic doses. Pollock and Harrison- also report good results 
following the use of this drug. The patient should be kept in the 
Fowler position, to favor drainage of the uterine cavity. Local 
measures, as previously suggested for the treatment of acute endome- 
tritis, should be adopted. 

Chronic Gonorrheal METRrris 

This condition is always preceded by an endometritis. In some 
cases resolution may have taken place in the mucosa, and when such 
specimens are examined, the latter may appear to be comparatively 
normal, whereas the inflammation of the underlying musculature 
still remains. Chronic gonorrheal metritis may follow in the wake of 
an acute attack, or may be subacute from the beginning. The extent 
of the involvement of the uterine musculature varies widely in dif- 
ferent cases. Thus in some patients only a slight subendometrial 
inflammation will be present, whereas in others the uterus may be 
found markedly enlarged, the chief pathologic lesion being very evi- 
dently in the uterine musculature. 

Symptoms. — These are in general similar to those of chronic 
endometritis, but they are, as a rule, more pronounced. Theilhaber 
and Meir' believe that in many cases the leukorrhea and uterine hem- 
orrhages that are said to result from an endometritis are in reality 

' Schindler, C: Arch. f. Gyn., Berlin, 1909, vol. Ixxxvii, p. 607. 

2 Pollock, C. E., and Harrison, L. H.: Gonococcal Infections, London, 1912, p. 122. 

' Thoilhaber and Meir: .\rch. f. Gyn., vol. Ixvi, No. 1, p. 1. 



caused by lesions in the myometrium, and that metritis is more fre- 
quent than is generally beheved. On pelvic examination of cases of 
metritis the uterus is found to be symmetrically enlarged and more 
or less tender on palpation. Both the enlargement and the tenderness 
are generally less marked than in the acute condition. According 
to Bell,' the muscular walls of the uterus, when infected during the 
puerperium, become bulky and haid (chronic "fibrotic" metritis). 

Treatment. — This is similar to that suggested for chronic endome- 
tritis. For intra-uterine applications after curetage Diaz- and Web- 
ster'' strongh' recommend formalin. The author, however, prefers 
the tincture of iodin. If, after two or more curetments, the symptoms 
still continue to be severe, and especialh^ if the uterine hemorrhages 
are intractable, a supravaginal hysterectomy and bilateral salpingec- 
tomy maj' become necessary. The plan suggested by Kell}', of ex- 
cising from the fundus a V-shaped portion of the uterine wall, 
including the endometrium, may be advisable in some cases in 
which the appendages are normal and the patient is especially desirous 
of maternity, although the probability of the latter taking place is 
small. The chief advantage offered by this partial hysterectomj' is 
that menstruation is not abolished. Kelly reports good results fol- 
lowing this method. 

Jayle and Loewy^ have employed Bier's method of hyperemia in 
a number of cases, with satisfactory results. These authors have 
devised a glass tube with a syringe attached that aspirates when the 
piston is pushed into the cylinder, and thus creates a vacuum. This 
enables them to dispense with assistance, which otherwise would be 
necessary, the cupping-glass being held in one hand and the asjiirator 
in the other. Each treatment lasts for about five minutes. The 
sittings are held daily, the number being regulated by the reaction 
elicited and the effect produced on the disease. The first application 
of Bier's cupping-glass to the cervix causes very decided pain in the 
pelvis and sacral regions, sometimes radiating to the thighs, but aft(>r 
a few treatments this pain disappears. 

In those cases of metritis complicated bj' intractable uterine 
hemorrhages vaj^orization luis been suggested as a means of either 
destroying the endometrium, or in severe cases of actually obliter- 
ating the uterine cavity. In the former event the operation offers 
no advantages over curetage, as previously described. As has 

' Ucll, \V. H : l'iiiiii|)l<>sof (lynccolopy, 1910. 

' Diaz: .ViinalfStio lu .\cii<i. deObstet., etc., .Madrid, HIIO, vol. iii, p. 03. 

' UVbstpr:!i,se.s of Wonu'n. 

•Jayle, I'"., and I.ocwv, K.: Vrrsao mM., Paris, l!ll)7, vol. xv, p. SVA. 


been indicated, the difficulty of accurately controlling the stream 
within the uterine cavity is the chief obstacle to successful treat- 
ment by this method. We have no means at our command, unless 
the curat is employed, of determining the actual thickness of the 
endometrium. Therefore the amount of steam necessary to destroy 
one endometrium, might in another case be sufficient to remove all 
the mucosa and a part of the underlying muscle, and result in ob- 
literation of the uterine cavity in an organ in which the lining 
membrane was thin, or might not remove sufficient tissue if the 
endometrium was greatly hypertrophied. Vaporization as a means 
of obliterating the endometrial cavity is justifiable only at the 
menopause, and even then, in the author's opinion, is inferior to 
hysterectomy, over which it offers no advantages, and the likelihood 
of such uteri subsequently producing distressing symptoms is very 
considerable. If even the intramural tubal mucosa is infected, vapor- 
ization offers no hope of cure. Flatau,' at a meeting of the Franconian 
Obstetrical Society, declared that from his own ten years' experience, 
and from that of others, the cases in which vaporization was justi- 
fiable before the menopause must be most exceptional. The same 
author further stated that vaporization should be used only when 
the strongest indications exist, and that the absolute obliteration of 
the uterine cavity cannot be insured without the employment of the 
soundest technic. On the other hand, Frankenstein- reports that he 
has applied vaporization 192 times in the Kiel Frauen-Klinik under 
Werth, for various conditions, with good pfimary results. He states, 
however, that in young patients, vaporization is not justifiable except 
under very exceptional circumstances. He believes that with carefully 
considered indications and accurate technic vaporization may be em- 
ployed successfully in the treatment of hemorrhages at the climacteric. 
Gellhorn,^ Polano,* Horrmann,^ Lewicki,** StSckel,' Jung,^ Eltze,' 
Wagner,'" Hasenfeld,'' Fett,'- Peham and Keitler,'^ Keilmann,'* and 

1 Flatau, S.: Samml. klin. Vortr., Leipzig, 1910, n. f. No. 585. 

- Frankenstein: Monats. f. Geb. u. Gyn., No. 2, p. 102. 

' Gellhorn, G.: Amer. Jour. Obstet., 1909, vol. Ix, No. 1. 

•■ Polano: Zentralbl. f. Gyn., 1901, No. 30. 

= Horrmann: Monats. f. Geb. u. Gyn., 1907. 

' Lewioki: Zentralbl. f. Gyn., 1906, No. 7, abstract. 

'Stockel: /bid., 1905, No. 48. Mung: Miinoh. med. Wochenschr., 1905, No. 52. 

" Eltze: Zentralbl. f. Gyn., 1907, p. 1602. 

•" Wagner: Naturforscherversammlung, Dresden, 1907. 

" Hasenfeld: Wien. klin. Wochenschr., 1907, No. 18. 

'« Fett: Monats. f. Geb. u. Gyn., 1905, p. 674. 

" Peham, H., and Keitler, H.: Beit. z. Geb. u. Gyn.; Rudolf Chrobak, 1903, p. 626. 

" Keilmann: St. Petersburg, med. Wochenschr., 1904, No. 28. 



manj^ others have employed dry heat for cases of metritis. This 
form of treatment is claimed to be especially beneficial in those cases 
that are accompanied by exudative processes within the pelvis. The 
presence of adnexal lesions do not contraindicate this treatment; it 
should, however, be employed only in chronic cases, and in those in 
which the temperature and pulse are normal. The treatments should 
always be administered under the control of a physician. Gellhorn^ 
has devised an excellent apparatus for the application of the hot air. 
This instrument is a modification of Kehrer's" apparatus, and con- 
sists of two semicircular cradles made of thin sheet-iron, and covered 
on the inside with asbestos. These two cradles lie one upon the other, 
and may be pulled apart in the fashion of a telescope. On the inside 
of the free edges eight electric-light bulbs are attached, and a long wire 
furnishes the connection with the nearest switch. A hole in the 
roof of the cradle is provided for the thermometer. This instrument, 
in Gellhorn's hands, has given excellent results. The mode of applica- 
tion is as follows: The apparatus, with the thermometer adjusted, 
is placed over the exposed abdomen and the electric light turned on. 
As it is best to apply the heat gradually, the apparatus is not covered 
with blankets for a few minutes. A temperature of 200° to 220° F. 
is usually employed. An ice-bag or a cold cloth is placed on the 
patient's head, and she is urged to drink large quantities of cool water. 
In about ten minutes the temperature reaches 180° F., and some 
patients will complain of intense burning. The' operator should be 
guided bj- the sensation of the patients, and should discontinue the 
treatment if it causes much discomfort. As the treatments advance, 
higher temperatures can usually be borne. All observers state that 
pain rapidly decreases, and a complete cessation of discomfort occurs 
after four or five treatments. In a certain proportion of cases there 
is only subjective improvement, but in the vast majority a diminution 
in the size of the exudate rapidly takes place. Polano' saw an old 
exudate of stony consistence, extending laterally to the right iliac 
bone, and upward to the umbilicus, disappear completely after 20 
treatments. In one of Burger's' cases a tumor reaching as high as the 
umbilicus was reduced by 18 treatments to a single cord the size of 
the finger. Keilnumn^ reports 50 cases; Peham and Keitler," 120 
cases, and Fett," 88 cases, the great majority of which were greatly 
improved or cured by this treatment. Sixty-five per cent, of Fett's" 

' (icllliorii: Loc.cit. Mvulircr: Zcntnill>l. f. Cyn.. I'.IOl, N'o. 52. 

" I'ohmo: (Quoted by Gellhorn: Loc.cit. * Burger: (Juoti'd by ( lellhorn: Loc.cil. 
' Keilmann: Loc. cil. * IVham ami Kciller: Loc. cii. 

' Felt: .Moiiats. f. Gt-b. u. Gyn., 1905, p. ()74. « Fell: Loc. cit. 


patients were cured, 7 per cent, improved, and 15 per cent, unim- 
proved. Of Peham and Keitler's^ cases, 58 per cent, were entirely 
cured, and 20 subsequently became pregnant. Treatments should 
be discontinued if an exacerbation of the inflammation occurs. 

In cases in which exudative processes are a marked feature Kirsten- 
advocates the injection, into the exudate, of normal salt solution, to 
promote its absorption. He has employed this treatment in three 
cases with good results, but, as he himself observes, the patients might 
have recovered as promptly if he had not resorted to this treatment. 
Mocquot and Mock^ recommend the injection of 30 to 40 per cent, 
solution of zinc chlorid. As the injections are painful, a preliminary 
injection of a 5 per cent, solution of cocain or novocain is advised. 
They report excellent results. The author has had no experience 
with this form of treatment, which is advocated by so many French 
surgeons. The injection of a more or less toxic solution into the base 
of the broad ligaments, or even into the parametrium, does not seem 
a sound mode of treatment, and it would appear that the patients 
recover despite, rather than because of, the injections. 

Gonorrheal intramural abscess of the uterus is an extremely rare 
condition. This may be explained by the fact that, as has been stated, 
the gonococcus is mainly a surface microorganism, and therefore does 
not usually obtain access to the uterine parenchyma. In 1892 von 
Franque,^ in an excellent monograph, reported 15 authentic cases of 
intramural abscess. The bacteriologic cause was not satisfactorily 
demonstrated in all cases, but 7 of them were dependent for their 
origin upon an infection following childbirth, so that it seems fair to 
assume that only the minority of these were gonococcal in origin. 
Five years later Noble" briefly reported 4 cases of abscess of the puer- 
peral uterus, making in all 8 that had occurred in his practice. He also 
reviewed 11 other cases collected from the literature. The following 
year Mercade^ reviewed the literature on this subject, and was able 
to find 41 authentic cases, of which 22 followed parturition, whereas 
in a recent paper Risch^ reviews 22 cases. Beyer* reports the history 

' Peham and Keitler: Beit. z. Geb. u. Gyn., 190:3, p. 026. 

= Kirsten: Zent. f. Gyn., December 25, 1909. 

' Mocquot and Mock: Rev. de Chir., 1912, No. 5, p. 779. 

■* von Franque: Samml. klin. Vortrage, new series, No. .316. 

^ Noble: Trans. Amer. Gyn. Soc, 1906, vol. xxxi,p. 296. 

^ Mercade: Annal. de Gyn. et d'Obstet., 1907, second series, vol. iv, p. 29. 

'Risoh: Medizinische Klinik, 1911, No. 5. 

» Heyer: JNIonats. f. Geb. u. Gyn., vol. x.xxi. No. 4. 



of a case, probably of streptococcic origin, which occurred four and 
one-half weeks after the delivery of the patient. Hysterectomy was 
followed by recovery. It is impossible to estimate accurately, from 
the foregoing reports, the proportion of these cases that were of 
gonorrheal origin. 

Lea^ reports a case occurring in a multipara following labor. 
This patient, during the last months of pregnancy, had a profuse 
leukorrhea. Labor was normal. The child developed ophthalmia. 
The patient convalesced satisfactorily until the twelfth day, when 
she developed hypogastric pain. This continued, although not of 
sufficient severity to confine the patient to bed, until six weeks after 
delivery, when she was seized with intense pain in the lower ab- 
domen, accompanied by rigor. The temperature was 103.6° F., and 
the pulse 130. The abdomen was distended and tender. Examina- 
tion revealed an enlarged and sensitive uterus. On section, the con- 
dition was seen to be due to the rupture of an intramural uterine 
abscess that was situated on the posterior uterine wall, one inch below 
the fundus. The appendages were normal. The patient made a good 
recovery. This case was of gonorrheal origin. In 1910 Sampson- 
reviewed the histories of 4 cases occurring in his practice, all of which 
followed parturition. None of these was due to gonorrhea. Fer- 
guson' briefly records the history of a case of pelvic inflammatory 
disease occurring in the puerperium, in which numerous small intra- 
mural abscesses were present. A large pyosalpinx was associated 
with the condition. Recovery followed a hysterectomy. The type 
of infection is not mentioned. Barrows^ reports 7 cases, only 1 of 
which was of gonorrheal origin. The reports of both Sampson and 
Barrows are most \'aluabh>, and cover the etiology and other important 
points of their cases thoroughly. From these reports it will be seen 
that of 11 carefully studied cases of intranuu'al uterine abscesses, but 
1 was of gonococcal origin. If we add to this series the case reported 
by Lea, we find 2, or 16.G6 per cent., of all cases due to this type of 
infection. Barrows and Sampson are of the opinion that intramural 
ab.scesses of the uterus are more frequent than is generally supposed, 
and that the condition is seldom diagnosed before operation. The 
former observer believes that many accumulations of pus within tlic 
uterine wall arc discharged into the uterine cavity, resulting in the 
recovery of the patient, without definite knowledge, on the part of the 

'Lea: .lour. Ohstot. and ( lyn., liiil. lOiiipiic, I'.IOI, vol. v, No. 2, p. l.'i!!. 
'Siiiiipson: .Xiiicr. Jour. Olwlt't., .March, li)l(l. 

" KerRiL-ion, J. II.: Tran.s. Edin. Olwt. Sor., I'JO.'j-Oll, vol. xxxi, p. 1;{1. 
' Barrows: Ainor. Jour. Obstct., .\pril, 1911, p. .57.5. 


medical attendant, of the presence of the abscess. Sudden gushes 
of pus from the uterine cavity, followed by relief of symptoms, have 
not imcommonly been attributed to the discharge into the uterus of 
the contents of a pyosalpinx. Barrows believes that many of these 
cases are in reality abscesses of the uterus. Again, pus inclosed in a 
shallow pocket beneath the mucosa may easily be evacuated by the 
curet, which has been brought into use because of the symptoms 
pointing to a serious inflammation of the endometrium; or the pus 
may burrow between the layers of the broad ligament, and, following 
the round ligament, present in the neighborhood of the inguinal ring, 
which, being opened and drained, would result in cure of the patient 
under a mistaken diagnosis. Purulent collections in the posterior 
uterine wall and low down, or even in the anterior wall, may be opened 
and drained imder the belief that they are ordinary pelvic abscesses. 

Sampson^ divides intramural uterine abscesses into two groups: 
The first, in which the uterine abscess or abscesses are the chief feature 
of the infection. In this class of cases the condition exists as a dis- 
tinct clinical entity. The second group consists of those cases in 
which the uterine condition is secondary in pathologic and clinical 
importance to other lesions resulting from the infection. 

Symptoms. — Intramural uterine abscesses of gonorrheal origin 
may be either single or multiple, the former being the more common. 
They may be situated either in the cervix or in the body of the uterus, 
but are apparently more frequent in the latter location and often 
single or few in number. They may be subperitoneal, interstitial, 
or submucous in type, or, as previously indicated, may extend out- 
ward between the layers of the broad ligament or between the uterus 
and bladder. Mercade- has emphasized their frequency near the 
uterine cornua. The abscesses vary in size, the largest one of which 
an accurate description can be found having had about the volume of 
an orange. The condition, like acute metritis without abscess forma- 
tion, is frequently preceded by labor, miscarriage, or abortion. In- 
([uiry will usually elicit the presence of symptoms of gonorrhea of the 
endometrium and of the lower genital tract. Pain is present over 
the lower abdomen, but this is not invariably a marked feature. The 
temperature and pulse are elevated, and the blood examiation is 
indicative of suppuration. The other symptoms of metritis previously 
described are present. Amenorrhea or irregular and profuse men- 
struation may be observed. All the symptoms are intensified at the 
menstrual periods. Examination of such a case reveals tendernesi 

' Sampson, C: Amer. Jour. Obstct., March, 1910. 

■ Mercade; Annal. de Gyn. et d'obstet., 1907, second series, vol. iv, p. 29. 




over the lower abdomen; the uterus is enlarged, and, if the case is 
one of puerperal origin, involution is delayed. On palpation the 
uterus will be found to be soft, boggy, and sensitive to pressure. It 
may in some cases be possible to palpate a softened swelling, originat- 
ing in the uterus, in which fluctuation can be detected. That the 
appendages -are not necessarily involved is proved by the cases of 
Lea^ and Barrows.- The cervix and lower genital tract usually exhibit 
evidences of gonorrhea. 

Diagnosis. — Intramural uterine abscesses are difficult to diagnose, 
and may be mistaken for a number of other pathologic conditions. 
Ordinary' pelvic inflammatory disease with extensive involvement 
of the appendages may produce lesions that render differentiation 
from this condition impossible. If the appendages are normal, the 
diagnosis is facilitated, as in this case the normal ovaries may be 
palpated. Uterine abscesses must also be distinguished from uterine 
myomata, and particularly from softened and degenerated tumors. 
The anamnesis will usually be of great aid in these cases, as in the 
case of mj'omata uterine hemorrhages, often extending over a number 
of years, and frequently associated with a thin, leukorrheal discharge, 
are generally present, whereas in case of intramural abscess the history 
frequently shows the condition to have had its origin shortly after 
childbirth or following a miscarriage. Furthermore, myomata are 
usually multiple, and evidences of infection are lacking; in the case 
of a single, softened mj^oma, however, especially if it is associated 
with a gonorrhea of the lower uterine tract, the differential diagnosis 
might easily be rendered impossible. Small ovarian tumors in which 
partial torsion has occurred and adhesions exist often simulate ab- 
scesses of the uterus. In many cases the probable diagnosis of this 
condition can be made only by exclusion. If, however, the facts are 
borne in mind that gonorrheal uterine abscesses are associated with 
gonorrhea of the lower genital tract ; that they most frequently occur 
at or near the cornua of the uterus; that they often have their origin 
in the puerperium; that the infection is usually of a low grade, com- 
pared with that produced by the streptococcus, and that the abscesses 
are accompanied by concomitant symptoms of metritis and endome- 
tritis — a tentative diagnosis should be possible in many cases. If 
untreated, the result will depend largely upon the number and loca- 
tion of the abscesses. If situated in the cervix, rupture into tlie vagina 
may occur and be followed by sjjontaneous cure. Rupture into tlie 
peritoneal cavity may take place, setting up a pelvic or a general in- 

' Lea: Jour. Obst. and Gyn., Brit. Emp., 1904, vol. v, No. 2, p. 1.59. 
' Barrow.s: Amer. Jour. Obst., April, 1911, p. .57.5. 


fection. The abscess may rupture into the endometrial cavity or 
into the bladder or intestines, especially the rectum or sigmoid flexure, 
or the pus may burrow between the layers of the broad ligament, 
finally presenting in the vagina as a pelvic abscess, or it may follow 
the course of the round ligament and point in the inguinal region. In 
rare cases the pus may become sterile and finally be absorbed. Bar- 
rows^ reports a case in which a calcareous deposit was formed in an 
old uterine abscess and simulated a calcareous myoma. 

Treatment. — This depends largely upon the location of the abscess. 
If it is so situated that the pus may be evacuated without traversing 
the peritoneal cavity, the abscess should be opened and drained at 
once. In all pelvic infections, and especially if they are of gonococcal 
origin, the general tendency at present is very properly toward delay- 
ing operation until the acute symptoms have passed. This is par- 
ticularly true if the infection is one that has arisen during the puer- 
perium. For this reason, if a uterine abscess is diagnosed, palliative 
treatment should be instituted provided it is impossible to evacuate 
the pus extraperitoneally. The patient should be confined to bed, 
the bowels regulated, and a nutritious, but easily assimilated, diet 
prescribed. If the case is a non-puerperal one, or if the os is firmly 
contracted, frequent hot vaginal irrigations, together with the applica- 
tion of local heat by means of turpentine stupes or large hot poultices 
to the abdomen, are indicated. Stimulation may in some cases be 
required. Ergot, owing to the fact that it causes uterine contraction, 
should not be administered. (For details of the palliative treatment 
of pelvic inflammatory disease see the chapter dealing with this con- 
dition.) The patient should be treated in a hospital and watched 
carefully, so that if symptoms of rupture of the abscess occur, an 
abdominal section can at once be performed. If the palliative treat- 
ment is successful, the operation should be delayed as long as the 
patient continues to improve, or until sufficient time has been allowed 
to elapse for the pus to become sterile. Under such circumstances 
the abdominal route is to be preferred to the vaginal, and should 
always be employed. 

Two forms of operative procedure are open to choice — incision and 
drainage of the abscess and hysterectomy. Noble- reports that 
hysterectomy has been attended with a mortahty of 25 per cent., 
whereas in 11 reported cases of incision and drainage none of the 
patients died. Cragin^ mentions 5 cases of multiple intramural uterine 

' Barrows: Amer. Jour. Obst., April, 1911, p. 575. 

2 Noble: Trans. Amer. Gyn. Soc., 1906, vol. xx.xi, p. 296. 

' Cragin: Amer. Jour. Obst., 1900, vol. liii, p. 779. 



abscesses occurring at the Sloane Maternity, upon whom hysterectomy 
was performed. The mortaUty was 60 per cent. Harrow^ also briefly 
reports a case of multiple abscess of the uterus caused by the strepto- 
coccus cured by hysterectomy. Vineberg- mentions two cases during 
the course of a discussion on puerperal thrombophlebitis in which the 
uterus was studded with abscesses, varying in size from a pea to a 
walnut. Davis^ records the history of a case in which an intramural 
abscess occurred in a patient on whom a cesarean section had been 
performed. The woman, having been discharged from the hospital 
on the fifteenth day, returned on the twenty-ninth day and died ten 
days later. The location, size of the abscess, and variety of infection 
are not mentioned. Robins* has reported a case that occurred in 
a patient twenty-seven j^ears of age, two weeks after childbirth; 
until this time the puerperium had been normal. The symptoms 
consisted of pain in the lower part of the abdomen, in the right side, 
and other evidences of infection. Supravaginal hysterectomy showed 
a single abscess in the- posterior uterine wall near the fundus, which 
contained about 2 ounces of thick, creamy pus. The etiology of the 
lesion is not mentioned in the report, but the fact that the tubes were 
found to be normal and the ovaries were adherent is against the gono- 
coccal origin of the condition. Harrigan" has reported the history of a 
case in which the patient had given birth to a child four days prior to 
her admission to the hospital. She suffered from cough and the usual 
symptoms of infection of the lower abdomen. At operation a large 
mass was found, consisting of uterus and adherent sigmoid. A large 
abscess was found on the posterior uterine wall, which had ruptured 
into the parametritic tissues. Hysterectomy was followed l)y recover}'. 
The type of infection is not stated. 

Barrows" favors drainage of these cases, and is particularly care- 
ful not to break up adhesions for fear of opening up avenues of in- 
fection. To effect drainage, he employs a large rubber tube, from V2 
to 5^4 iiicli ill diameter. This tube is carried well into the abscess 
cavity, and held in position by an ingenious suture that passes through 
the abscess wall and rubber tube and is tied outside the wountl. This 
suture keeps the tube in place, and yet may be loosened at any time 
without causing pain or disconifort to the patient. 

The choice of the operation is dependent upon a number of factors, 

' Harrow, .J. A.: Bull. Lying-in Hosp., New York, March, lUll, p. 172. 
' Vineberg, H. M.: Jour. Ainer. Med. .\ssoc., July 20, 1912, p. 1G4. 

* Davis, A. B.: Amcr. .lour. Obst., December, 1912, p. 940. 

* Kobin.s, C. U.: (Jltl Dominion Med. and Surg. Jour., 1911, vol. xiii, p. 277. 
' llarrigan, \. H,: .Vnier. Jour. ObMleL, September, 1912, p. 46S. 

' Barrows: Luc. cil. 


which are generally similar to those that govern the operator in making 
his decision in cases of ordinary pelvic inflammatory disease. The 
type of infection is important in determining this point. If the ab- 
scess is single, large, walled off, and is so situated that drainage can be 
satisfactorily established, this operation is the safer one to perform. 
If, however, the appendages are extensively involved, hysterectomy 
offers the best hope of securing an entire symptomatic cure. In 
operating on these cases special care should be taken to avoid contam- 
ination of the peritoneal cavity. 

The following is the history of a case that was operated upon in 
the Gynecological Department of the University of Pennsylvania 
Hospital : 

Path. No. 4i08. — Age, twenty-five years. Shortly after marriage, 
four years ago, a profuse purulent leukorrhea and symptoms of ure- 
thritis appeared, followed later by a labial abscess. One child three 
years ago. The puerperium was complicated by pelvic peritonitis. 
Since then sterility and occasional attacks of pelvic peritonitis. For the 
last year has had a cough, which has not yielded to treatment, and a 
slight loss of weight. Examination on admittance to th^ hospital showed 
a small tuberculous lesion in the left apex and a moderately massive 
pelvic inflammatory disease. It was the latter condition that brought 
the patient to the hospital. Diplococci, morphologically and tinctori- 
ally similar to gonococci, were demonstrated in the secretions from 
the cervix and from one of Bartholin's glands. A supravaginal hys- 
terectomy and a bilateral salpingo-oophorectomy were performed. 
Convalescence was somewhat prolonged, but otherwise normal. The 
pathologic examination of the uterus and appendages showed thejn 
to have the usual appearance of pelvic inflammatory disease. The 
tubes were converted into pyosalpinges. The abdominal ostia were 
closed, and no fimbrite could be distinguished, nor were there any tu- 
bercles present upon the peritoneal surface. One ovary was the seat 
of a small abscess, evidently the result of an infection of a corpus 
luteum; the other was enlarged, covered with adhesions, and con- 
tained a number of retention cysts. The uterus was normal in size, 
and in the left cornua, somewhat anterior to the median line, was a 
semifluctuant swelling, 2.5 by 2 by 1.5 cm. Histologic examination 
showed this to be an intramural abscess, not communicating with 
the tube. No gonococci could be demonstrated in the appendages 
or in the intramural abscess. Numerous tubercles, many of which 
contained typical giant-cells, were present. This case appears to 
have been one in which tuberculosis was implanted upon a preexist- 
ing gonococcal infection. Whether the intramural abscess was the 
result of tuberculosis or of gonorrhea it is impossible positively to de- 



Gonorrhea of the endometrium may, and frequently does, extend 
to the tubes, and from these to the ovaries. Gonorrheal infection 
has been observed to reach the tubes in less than two weeks after the 
initial contamination of the cervix. This, however, is unusual; as 
a rule, a much longer time elapses before involvement of these struc- 
tures takes place. The relative frequency with which the appendages 
are invaded in comparison with gonorrhea of the endometrium is 
difficult to estimate accurately, but it seems likely that if the mucosa 
of the body of the uterus becomes infected, in the majority of cases, 
at least, the disease extends to the tubes, and from the latter to 
the ovaries. ^lenge,^ in combining the statistics of Bumm, Stein- 
schneider, Fabry, Briinschke, Brose, and Welander, found that the 
tubes, ovaries, and pehdc peritoneum were involved in 25 per cent, of 
the acute and in 50 per cent, of the chronic cases. As Bumm- has 
amplj^ proved, and as previously stated in this work, the gonococcus 
is chiefly a surface microorganism, so that the first lesion produced in 
the tube by this type of infection is a catarrhal inflammation. Tlie 
inflammation, however, quickly spreads from the superficial portions 
to the deeper layers of the tube, so that in advanced cases the muscu- 
laris and serosa are extensively involved. Wertheim^ and others have 
repeatedly demonstrated the presence of gonococci in the depths of 
the tubal wall. A moderate amount of cellulitis is usually present 
as an accompaniment of advanced tubal disease. Gonorrhea travels 
by continuity along the mucous membrane. Rare exceptions to this 
are occasionallj' noted, as sometimes in cases of extensive cellulitis 
or in gonorrheal endocarditis and other metastatic gonorrheas. As a 
result of the salpingitis an inflammatory exudate forms, which, when 
it e.scapes from the abdominal ostivun, produces at first a peri-oophor- 
itis and localized peritonitis. This may increase in gravity until an 
oophoritis or even an ovarian abscess results. The same cause brings 
about a more or less extensive pelvic jjeritonitis, which is usually 
most marked in areas innnediately surrounding the tuljal open- 

' Menge, V.: Handb. d. Geschlechtskrankheitcn, Vienna, I'JIO. 
' Bumm, E.: Tlierap. d. Gcgenwart, 190!), No. 1, p. 51. 
' WerLhcim, E.: Ccnlrulbl. f. Gyn., 189G, No. 4)S, p. 1-'0<J. 


ings. Adhesions of the tubes, ovaries, uterus, and adjacent structures 
are thus produced. In many cases the abdominal ostia of the tubes 
become closed, and the tubal contents are thus walled off from the 
peritoneal cavity. Nevertheless, during subsequent exacerbations of 
the pehic infiammatorj^ disease more pus or exudate from the tubes 
frequently leaks out through the tubal openings, and toxins, or even 
gonococci, escape through the walls of the oviducts, so that in ad- 
vanced cases the entire contents of the pelvis may be found matted 
together in a mass of dense adhesions. Owing to the increased weight 
of the tubes during the early stages of the inflammation, these organs 
sink deeper into the pelvis and are not infrequently found adherent 
to the posterior surface of the broad ligament, to the rectum, or in 
Douglas' culdesac. In advanced cases of pelvic inflammatory disease 
accumulations of pus may be found between the adnexa and the ad- 
jacent structures, and walled off from the general peritoneal cavity 
by adhesions. Both appendages are generally involved, although not 
infrequently infection on one side may antedate that on the other. 
It is not usual, however, to find a large inflammatory mass composed 
of a pyosalpinx and an inflamed ovary on one side, whereas on the 
other little more than a perisalpingitis will be found. 

The number of previous attacks of acute pelvic peritonitis are of 
importance in this connection. After a patient has had a number of 
attacks it is rare to find a normal tube on either side; so, also, if a 
pyosalpinx has been present on one side, it is rather unusual for the 
opposite tube, to be entirely normal. No hard and fast rule can, 
however, be formulated regarding this point. 

Pelvic inflammatory disease may be produced by germs other 
than the gonococcus, although this organism is the most frequent 
causative agent. The etiology of pelvic inflammations is of the ut- 
most importance, as the prognosis varies quite widely in the different 
types of infection. If it were possible for the surgeon, before com- 
mencing his operation, to know positively what form of infection he was 
dealing with, a great advantage would be gained. Unfortunately, 
this is not practicable in all cases, for occasionally rare microorganisms, 
such as some of the air bacilli, or mixed infections will defy all diag- 
nostic means except the incubator, and this is, of course, not available 
until the abdomen has been opened and is, therefore, valueless as a 
surgical guide. Nevertheless, the great majority of pelvic infections 
may be classed under three headings: the gonococcal, the pyogenic 
(streptococcus or staphylococcus), and the tuberculous. The dif- 
ferentiation between these varieties is not usually difficult. The 
relative frequency with which the gonococcus is found will be shown 



by the following statistics: Andrews^ reports, in the order of their 
frequency, the following microorganisms: Gonococcus, 43 percent.; 
pyogenic (streptococcus and staphylococcus), 24 per cent.; colon 
bacillus, 5 per cent.; pneumococcus, 4 per cent.; tubercle bacillus, 
1 per cent, to 3 per cent. Menge- records the results obtained from 
cultures of pus from 106 cases of pyosalpinx: Sterile, 68, or 64 per 
cent.; gonorrheal, 22, or 21 per cent.; tuberculous, 9, or 8 per cent.; 
streptococcal, 4, or 4 per cent.; staphylococcal, 1, or 0.96 per cent.; 
anaerobic bacilli, 2, or 3 per cent. Ki-6nig' reports the bacteriologic 
examinations of 122 cases of suppurating tubes as follows: Sterile, 
75, or 61 per cent.; gonococcal, 28, or 23 per cent.; tuberculous, 8, or 
7 per cent.; pyogenic, 4, or 3 per cent.; other forms, 7, or 6 per cent. 
Miller^ examined pus from 43 cases of pyosalpinx, ovarian abscess, and 
other inflammatoiy adnexal lesions, and found 33 sterile, 7 gonococcal, 

I pyogenic, and 2 unidentified forms of microorganisms. Hyde,^ 
in an examination of 2973 cases, excluding those of tuberculous origin, 
reported the tubal contents sterile in 1998 cases, or 67 per cent. The 
gonococcus was recovered in 579 cases, or 19 per cent., whereas other 
or mixed infections were present in 456 cases, or 15 per cent. Xoeg- 
gerath and Wertheim* examined 312 cases, with the following results, 
excluding all tubercular specimens: Sterile, 122, or 39 per cent, of cases; 
gonococci were found in 56 cases, or 18 per cent.; streptococci, in 

II cases, or 4 per cent.; staphylococci, in 6 cases, or 2 per cent. 
Pankow' has reported that statistics computed from the University 

Clinic of Freiberg, these show 43 per cent, of suppurating tubal lesions 
due to gonorrhea, 22 per cent, to tuberculosis, and 22 per cent, to secon- 
dary infection from the appendix. Schridde,** however, has not seen a 
single case due to appendicitis out of 280 under his personal observa- 
tion. Heyneman,^ from an analysis of 47 cases, showed that 58.8 per 
cent, were due to the gonococcus, 23.5 per cent, to the streptococcus, 
11.7 per cent, to the tubercle bacillus, and 5.8 per cent, to the staphj^- 
lococcus. Lock,'" in 22 cases, found gonococci in 3; 10 were sterile, and 

'Andrews: Quotcil hy (lihndrc. ,1. I{.: Aincr. .lour. Ohsict., April, KUD, p. VMi. 

■ McnRc: Ccntnill)!. f. Gyn., ISi).'), vol. xix, p. 7i)i). 

' Kroniu, Menge and: Bact. d. weibl. GenitalkanaLs, Leipzig, 1S97, pt. 1, p. 204. 

' .Miller: Quoted hy Cro.sscn: Trans. .\mor. Gyn. .Soe., I'hiladelpliia, 190i), vol. xxxiv, 
p. tiOJ. 

> Hyde, C. R.: Ainer. .Jour. Obstct., 1908, vol. Ivii, p. 49(i. 

' Noegnerath and Wertheim: Quotctl by Crossen: Trans. Anier. Gyn. Soe., 1909, 
vol. xxxiv, p. ()()'J. 

' I'ankow: (^uolecl by de Bovis: La Scmainc MMieale, September 4, 1912. 

'Scliridde: (Quoted by de Bovis: Loc. cit. 

■ Ileynenian: Zeit. f. Gel., u. Gyn., 1912. 

" Lock, N. I''.: .Jour. Obst. and Gyn., Brit. lOup., .July, 1912, [). 1. 


in the remainder 10 different organisms were demonstrated. An analy- 
sis of the foregoing statistics shows tliat of 3501 cases, the gonococcus 
was demonstrated in the lesions 718 times, or 17.4 per cent. A per- 
centage of 17.4 does not, however, by any means represent the actual 
proportion of those cases which were of gonorrheal origin; for, apart 
from the well-known difficulty of demonstrating the gonococcus by 
either culture or staining methods in chronic cases, it is a well- 
established fact, and one of great clinical importance, that long en- 
capsulation tends to destroy the gonococcus, perhaps by its own toxins. 

Gurd,' after a careful study of 20 cases of salpingitis, states that he 
believes the gonococcus to be the exciting factor in the production 
of the affection in at least 80 per cent, of his series. He further adds 
that the reason many bacteriologic tests for this organism are negative 
is that the material for examination is obtained from the free pus 
in the abscess cavity. If the material is removed by curetage from 
the wall of the abscess, there is a much greater likelihood of obtaining 
positive results, as the gonococci persist in a virulent state in such 
areas long after those in the free fluid become attenuated or are 
totally destroyed. It is well recognized that gonococci can be demon- 
strated in the tubes in only a small proportion of chronic cases of 
salpingitis, even by the most painstaking and thorough bacteriologic 
examination. This must be considered in analyzing the foregoing 
figures. Furthermore, in many cases the gonococcus appears to 
prepare the soil for subsequent infection by other microorganisms, so 
that even in c^ses in which other organisms are demonstrated, gono- 
cocci may have caused the primary lesions. A careful study of the 
history of each case, together with a thorough examination of the 
cervix, urethra, and vulvovaginal glands, would throw light upon 
this point. 

Guthrie collected statistics from 15 surgeons in Iowa, and found 
that 70 per cent, of all cases of pelvic inflammatory disease were of 
gonococcal origin. Price claims that 90 per cent, of all pelvic in- 
fections are of gonococcal origin. Norris places the proportion at 
80 per cent. ; Pozzi and Frederic, at 75 per cent. ; Clark, at 50 per 
cent.; Heynemann,^ at 66 per cent.; Robb, at 25 per cent.; Davis 
and Noble, at 5 to 10 per cent. The diversity of results obtained can 
doubtless be largely accounted for by considering the material from 
which the statistics were compiled, for, as is well known, some clinics 
operate on large numbers of pelvic inflammatory cases, whereas in 
others they will but comparatively rarely be observed. 

' Gurd, F. B.: Jour. Med. Research, 1910, vol. xxiii; new series, vol. xviii, pp. 151-175. 
2 Heynemann: Zeit. f. Geb. u. Gyn., 1912, vol. Ixx, No. 3. 


The great importance of accurate diagnosis in respect to the 
microorganism producing the lesion is shown by a study of the beha- 
vior of the various organisms within the Fallopian tubes. A large pro- 
portion of gonorrheal adnexal lesions ultimately become sterile. The 
gonococcus doubtless constitutes primarily the infective type of micro- 
organism in many of those cases in which no growth upon culture- 
media can be obtained. The time required to effect death or 
successful attenuation of the gonococcus within the Fallopian tube 
is from one and one-half to three months, although in exceptional 
cases the microorganisms may survive a longer period, as shown by 
Neisser,^ who examined 143 cases of gonorrheal pelvic inflammatory 
disease, all of which had remained latent for a period of at least two 
months and some for as long as eight years. In 8 cases of this series 
gonococci were found. It is probable that in most of these 8 cases 
the virulence was greatly attenuated. If both ends of the tube are 
entireh' occluded and the tubal walls are thick, the death of the in- 
fecting microorganism occurs more rapidlj' than if a more or less con- 
stant leakage of the tubal contents is taking place. The pyogenic 
microorganisms are much more erratic than the gonococci, and fre- 
quently become encapsulated, not losing their virulence for prolonged 
periods. Thus IVIiller- reports two cases, in one of which streptococci 
existed for six years, and in another, for twelve years; Martin' men- 
tions a case of nineteen years' duration. In not a few cases of pel- 
vic inflammatory disease mixed infections are present, as was proved 
by Hyde's' statistics. Aside from the direct influence of the specific 
microorganism, inflammation of the uterine adnexa may result from 
the action of toxins, although exactly to what extent this occurs has 
not yet been definitely determined. Wertheim* was the first to dem- 
onstrate the presence of gonococci in pure culture in salpingitis and 
also in circumscribed pelvic peritonitis. 

Symptoms. — These vary according to the extent of the lesion 
and the stage of the disease. Thus, when a pyosalpinx is walled off 
by adhesions it prol)ably will not cause so much disturbance as a 
much milder inflammatory process of a tube the abdominal ostium of 
which is patulous and leaking. 

' .N'oisser: (Quoted by Crossen: Trans. Aiiicr. (lyii. Soc, I'.H)'.), vol. xxxiv, p. M2. 
' .Miller: (iuoled by Kelly: Oporativt- Gynecology, IS'J'J, vol. ii, p. 211. 
' Miirtin, F. H.: Surg., Gyn., and Obstet., April, 1907, p. 501. 
* Hyde: Amer. .Jour., 1908, vol. Ivii, p. 490. 
' Wertheini: .Arch. f. Gyn., Berlin, vol. xlii, p. 1. 


The extension of the infection from the uterus to the Fallopian 
tube usually follows a menstrual period, or the emptying of a 
gravid uterus. When there is a latent gonorrheal infection of the 
endometrium, the disease is often spread to the tubes by some intra- 
uterine manipulation, performed for the relief of dysmenorrhea or 
sterility. The subjective symptoms are similar to those of metritis, 
except that when the tubes are involved the pain and tenderness are 
more diffuse and are not, as in the former, confined to the region of the 
uterus, but extend over the affected area. Furthermore, owing to 
the more extensive involvement of various organs, the symptoms are 
likely to be more severe. Bumm' and Menge- rightly lay especial stress 
on the question of pain as a diagnostic feature, and believe that this 
is always much more severe when the disease extends to the tubes 
than when it is confined to the uterus. In the latter case pain is 
often a marked symptom only at the menstrual periods. 

The symptomatology of salpingitis and its accompanying inflam- 
mation is defined only with extreme difficulty, owing to the numerous 
structures that may be involved. The initial symptom indicative 
of an involvement of the Fallopian tubes is frequently a chill, followed 
by nausea, vomiting, malaise, headache, elevation of the temperature, 
and increased pulse. In gonococcal cases the temperature rarely 
rises above 103.5° F. or the pulse-rate above 130, and more frequently 
both fall below these figures. A blood-count shows an increase in 
the number of leukocytes. The appetite is lost, and the usual symp- 
toms of fever, are present. Rectal or vesical tenesmus may be 
marked if the inflamed appendages are adherent to or press against 
either the rectum or the bladder. Rectal tenesmus is a frequent con- 
dition. The disease may be unilateral or bilateral; in some cases 
both tubes are infected simultaneously, whereas in others only one 
side is attacked. As the inflammation spreads by direct extension 
from the endometrium, infection may occur at any time while the 
endometritis persists. The severity and duration of the attacks vary 
quite widely in different cases. The local symptoms are only a 
moderately reliable indicator as to the extent of the disease. Not 
infrequently, in severe cases, owing to the wide-spread abdominal 
tenderness, pain, and tympanites, a clinical picture suggestive of 
general, rather than pelvic, peritonitis will be presented. Vaginal 
examination at this time will reveal evidences of gonorrhea in the 
lower genital tract. The uterus will be found enlarged, softened, and 
tender. Induration will usually be present in one or both vaginal 

' Bumm: Therap. d. Gegenwart, 1909, No. 1, p. 51. 

2 Menge, K.: Handbuch d. Gesehlec-htskrankheiten, Vienna, 1910. 


fornices. The cervix will be more or less fixed, and attempts to move 
it will cause pain, not only in the uterus, but in the ovarian regions 
as well. An inflammatorj^ mass, varying, according to the extent 
and character of the lesion, from a slight thickening, induration, or 
indistinct sense of resistance to a tumor the size of a grape-fruit or 
larger, will be found occupj'ing the region of the appendages. 

During the acute stage, owing to tenderness and tympanites, it is 
often impossible accurately to outline the adnexal lesions. ^lenstrual 
disturbances are often present, but these are probablj' due largely to the 
accompanj^ing endometritis and metritis. Ovarian involvement also 
influences the bleeding. The tubal contents at this stage contain 
numerous typical gonococci. The duration of the acute attack varies 
from a few days to two or three weeks. Unless complications arise, 
the disease rarel}-, if ever, ends fatally, but usually gradually subsides 
and merges into the chronic state. 

The chronic stage of pelvic inflammatory disease can almost invari- 
ably be traced to an acute attack, but occasionally, in mild cases, the 
disease is subacute and follows an almost chronic course from the be- 
ginning. The symptoms varj^ according to the extent and character of 
involvement of the pelvic structures. In mild cases, during this stage, 
the subjective symptoms may be almost entirely absent, or consist 
at most only of discomfort at the menstrual periods. More commonly, 
however, the disease, for the first year or two, is progressive. Exacer- 
bations from the chronic stage, occurring at irregular intervals, caused 
by leakage of the tubal contents, may occur at any time, but are more 
prone to occur at a menstrual period, after emptj'ing of a pregnant 
uterus, during the puerperium, following trauma, such as intra-uterine 
manipulations or treatment, or even after excessive or violent sexual 
intercourse. In this way extensive pelvic pathologic changes may be 
produced that practically render the patient an invalid. 

Menorrhagia and metrorrhagia are often present, together with the 
symptoms of cervical gonorrhea. In exceptional cases amenf)rrhea or 
scanty menstruation may be observed. Although no definite rule can be 
formulated regarding this point, it is probable that changes in men- 
struation bear a more or less direct relation to the amount of ovarian 
involvement. Boldt' states that if the tubal disease does not cause 
pathologic changes in the ovaries, the menstrual type is not likely 
to be changed. In those cases of hydrojis tuba- profluens there may 
be an occasional noticeable discharge of the tubal contents through the 

' Boldl. II. .1.: .Jour. Aiii.T. Med. Assoc, .Inly i:i, IIU.'. p. Kll. 


vagina, followed by temporary relief of symptoms and a subsidence of 
the tul^al enlargement. Pain in the lower abdomen is generally present, 
and is usually most marked on that side in which the lesions are most 
severe. In some cases, owing to the involvement of adjacent sensory 
nerves, pain is referred to the thighs or external genitalia. Owing to 
the presence of numerous adhesions, distress is often caused by the peri- 
staltic movements of the intestines — the so-called "gas pains," the 
pain being colicky in character. It is possible that in some instances 
colicky pain may be caused by contractions of the tubal walls. The 
amount of pain present is not always an indication of the extent of 
the inflammation, as in some very serious cases the patients suffer 
only a slight discomfort, whereas in others exhibiting but a compara- 
tively mild lesion marked subjective symptoms occur. Indeed, the 
general excellent physical condition and small amount of disability are 
most remarkable in some cases. They are, however, the exceptions. 
The character of the pain may also vary widely in different cases. 
In some it may be acute and agonizing, whereas in other patients there 
may be merely a sensation of weight and dragging in the pelvis. As 
a rule, rest in bed or the application of heat to the lower abdomen 
alleviates the pain. Defecation is often painful, especially in those cases 
in which the appendages are adherent to the rectum. As a result, 
constipation is often a marked feature. It is caused not only by 
actual pressure on the rectum, but is often due to the fact that, be- 
cause of pain, the act is delayed as long as possible, and a costive 
habit results. .This accumulation of hard feces within the pelvis 
tends in time to augment the pelvic inflammation, and in this manner 
a vicious circle is established. In some patients the symptoms re- 
sulting from the sluggish action of the bowels constitute in themselves 
a marked feature of the case. If the tube and ovary lie anterior 
and are adherent to the bladder, vesical symptoms, such as frequent 
and painful micturition, are more or less pronounced. Unless a pelvic 
examination is made, the condition may be mistaken for cystitis, while 
distention of the bladder or the emptying of a distended bladder may 
cause pain. Pain in the lower lumbar and sacral region is often present, 
and in some cases is most severe. Frontal or occipital headache may 
be a more or less marked symptom. Dming the chronic stage the 
pulse and temperature are usually normal, for during this period the 
exudates are confined by adhesions. For the same reason the blood 
examination is, as a rule, negative, or shows only a slight leukocytosis. 
All the symptoms are usually ameliorated, and the patient generally 
feels more comfortable early in the morning than after she has been 
about for some time. The discomfort is increased by exercise or by 


the pressure of tight clothing about the waist or lower abdomen. As 
a rule, the more chronic in nature the disease is, the more rarely is 
pain a prominent symptom. The symptoms are usually more pro- 
nounced for a few daj's prior to and during the menstrual periods. 
AVhen the menopause has become established, the suffering is fre- 
quently alleviated or disappears entirelj\ Dj-smenorrhea is almost 
always present, and may in some cases be the chief subjective symptom. 

Although the character of the dysmenorrhea may vary, it is usually 
of the congestive type. It generallj' begins from twelve to forty-eight 
hours before the appearance of the menstrual flow, and becomes 
severe after the second or third day. The pain is of a dull, heavy, 
aching character, and occurs in the lower part of the abdomen, and 
is frequently worse on that side upon which the lesions are most 
severe. Backache in the sacral and lower lumbar regions is often 
present. During the dysmenorrhea tenderness is increased over the 
diseased areas. At the menstrual periods pain and tenderness in the 
inguinal regions are frequently complained of. Dyspareunia of varying 
severity usually exists, and if the tubes are not patulous, absolute 
sterility is the result. As a rule, the fimbriated extremitj' of the tube 
becomes occluded early during the course of the inflammatory process. 
So long as the uterine end of the oviduct remains patulous and in- 
fective material escapes through the uterine cavit)-, the symptoms of 
an endometritis will persist. 

The vermiform appendix is involved secondarily in a large proi)or- 
tion of cases of pelvic inflanunatory disease, especially when the right 
adnexus is affected, the condition usually taking the form of a peri- 
appendicitis. As a result, tenderness over McBurney's point is often 
observed. Exacerbations from the chronic stage are frequent, es- 
pecially during the first year or two of the disease. These often follow 
trauma, or may result from no assignable cause. The recurrent 
attacks of jielvic peritonitis are cau.sed by a leakage from the tube of 
infective material, which sets up local peritonitis. The leakage may 
occur from the abdominal ends of the tube, or irritation of the adjacent 
peritoneum may result from toxins or even actual gonococci passing 
through the tubal wall. 

Constitutional .sj^mptoms vary widely, according to the individual 
case. The patient is usually more or less incapacitated and tires 
easily. At times loss of weight, anemia, and general ill health are 
present, although in other, apart from the pelvic symptoms, 
the patient may appear to be robust and well. Tenderness over the 
lower abdomen is often marked, and in severe cases the gait may \)o 
almost characteristic, the patient walking slowly, stoDjjiiig forward, 


often inclining slightly to one side or the other, a hand being placed 
over the site of the pain. As a result of prolonged suffering, impaired 
general health and neurasthenia not infrequently result. 

Abdominal palpation reveals the presence of resistance and tender- 
ness over the affected areas, and in thin subjects, or when the lesion is 
massive, a tumor may at times be felt in one or both ovarian regions. 

Vaginal examination reveals the evidence of gonorrhea in the lower 
genital tract. Induration and tenderness are often present in one or 
both vaginal fornices. The cervix is somewhat fixed, and attempts 
to draw it down or move it in any direction cause pain in the ovarian 
regions and the broad ligaments. The uterus is frequently in retro- 
position and adherent, and may be somewhat enlarged. The tube 
and ovary are often bound together in an indistinguishable, adherent, 
tender, inflammatory mass, over which, in cases of large accumula- 
tions of fluid, fluctuation may be elicited. This is more likely to be 
noticeable in thin patients and in those in whom the tubal walls are 
attenuated. More often fluctuation is absent, and the tumor has a 
hard, elastic feel. Occasionally the ovary can be palpated as a sepa- 
rate structure, but frequently this is not practicable, and in some cases 
the appendages of the two sides cannot be differentiated. The in- 
flamed masses may be bilateral or unilateral, one side usually being 
more extensively involved than the other. The longer the disease 
has persisted, and the more numerous the acute exacerbations have 
been, the more likely is the condition to be bilateral. In long-standing 
chronic cases, .therefore, bilateral salpingitis is usually present. The 
differentiation between a pyosalpinx, a hydrosalpinx, and a hema- 
tosalpinx is in many cases impossible. In purulent cases a slight 
elevation of temperature, perhaps of a half or one degree, is significant. 
On palpation a pyosalpinx frequently imparts a hard or doughy sensa- 
tion to the examining finger, whereas serous tubal accumulations are 
more elastic and often less adherent. Inflammatory hydrohemato- 
salpinges give the same general sensation on palpation as do simple 
serous accumulations. The rare cases of hematosalpinx not due to 
tubal pregnancy impart a soft, doughy feel to the examining finger. 
The typical retort shape often assumed by non-purulent tubal ac- 
cumulations sometimes acts as a guide in ascertaining the variety of 
lesion present. 

Occasionally the tubes are small and soft, and in these cases the 
demonstration of salpingitis by means of palpation is extremely dif- 
ficult and may be impossible without the administration of an anes- 
thetic. Fixation of the ovary is always significant. It is in these 
cases especially that the history will be of great assistance in formulat- 


ing a correct diagnosis. The age and social position of the patient 
are of importance, for although pelvic inflammation may be present 
in virgins, its pathogenesis in these cases can rarely be traced to gon- 
orrhea; on the other hand, this type of infection is the most frequent 
in the married and among women of loose morals. The previous 
history of the case often discloses the fact that the symptoms ap- 
peared after a labor or a miscarriage that was followed bj' "chills and 
fever," or the patient may state that her ti'ouble originated in an 
attack of "inflammation of the bowels." Gonorrheal salpingitis is 
always preceded by gonorrhea of the lower genital tract, so that a 
history of a purulent leukorrhea or other evidence of infection occur- 
ring shortly after marriage or after a suspicious intercourse is of especial 
significance. In these cases a historj^ of good health and of an entire 
absence of pelvic symptoms prior to marriage is very suggestive. 
Sterility, either absolute or of the "one-child" variety, provided that 
no means to prevent conception ha^•e been emploj'ed, is a very common 
feature in cases of pelvic inflammation of gonorrheal origin. 

A remarkable case of fecundation after bilateral pyosali)ingitis 
has been reported by Gradl,' in which, within four months after 
bilateral pus-tubes had been diagnosed during a laparotomy, the 
patient became pregnant and subsequently went thi'ough a fairly 
normal labor and puerperium. Rupture of a pus-sac into the rectum 
had taken place during the acute stage of the salpingitis, and discharge 
of pus through the anus continued until the middle of pregnancy. 
Gradl believes that the ovum must have found its way either through 
one of the tubes, which healed spontaneously, or that a sinus per- 
mitted a comnmnication between the ovary and the closely adherent 
tube, so that the Graafian follicle projected into the lumen of the 

Recurrent attacks, at irregular intervals, of pelvic peritonitis, 
lasting for a few days or more, the interim being characterized bj' 
comparative health, are typical of this type of infection. In many 
instances chronic invalidism and neurasthenic symptoms result. 

Diagnosis. — This is usually readily made if the anamnesis of the 
case is considered and a careful examination is performed. Excep- 
tional cases may, however, be encountered in which it is difficult to 
arrive at a positive diagnosis. The most frcciuent conditions with 
which pelvic inflammatory disease of gonorrheal origin is likely to be 
confouniled are: Tuberculo.sis of the tubes and ovaries; small ad- 
herent neoi)lasms, especially dermoid cysts; small adherent uterine 
tumors, such as niyomata; ectopic pregnancy, ]iarticularly in cases 

■ Cn.dl, II.: Zcnt. f. Cyn., April 27, I'.UJ. 


of tubal rupture and suppuration; cellulitis of the broad ligament, 
and oophoritis of pyogenic origin. A right-sided gonorrheal sal- 
pingitis may be mistaken for appendicitis. The differential diagnosis 
between gonorrheal pelvic inflammatory disease and appendicitis 
is not usually difficult. Tuberculosis often occurs in virgins, and 
is not infrequently associated with tuberculous lesions in other parts 
of the body. Dermoid cysts are generally unilateral, and a normal 
ovary may often be felt on the opposite side. These tumors are 
likely to occur in unmarried young women, and are especially prone 
to be found lying anterior to the uterus (Olshausen's sign). The 
history is often of great aid in excluding uterine myomata. Pehdc 
examination usually reveals the enlarged, nodular character of the 
uterus. When, however, the tumors are very small and intramural 
in type, and are associated, as they frequently are, with adnexal 
inflammatory lesions, the differential diagnosis is particularly difficult, 
and, unless the asymmetry of the uterus can be distinguished, mistakes 
may easily be made. Snegireff' states that when pain is due to an 
inflammatory process, it is generally of acute onset, and then gradually 
subsides. Inflammatory pains are accompanied by fever and other 
symptoms of infection, and the application of cold tends to relieve 
them, whereas in pain resulting from neoplasms, the converse is likely 
to be the case. The history in cases of ectopic pregnancy and the 
finding, in Douglas' pouch, of a doughy mass, having the peculiar, 
almost characteristic, crepitant feel produced by clotted blood, will 
usually be sufficient to establish the diagnosis. 

The differential diagnosis before rupture is usually comparatively 
easy; the amenorrhea, followed by irregular bleeding, the concomi- 
tant symptoms of pregnancy, the absence of previous attacks of pelvic 
peritonitis, the lower temperature, and the results of the pelvic ex- 
aminations are usually sufficient to establish the diagnosis of ectopic 
pregnancy. After rupture has occurred, the diagnosis is not always 
so easy; however, the liistory of sudden pain in the ovarian region, 
sometimes occurring after a slight physical effort, followed by the 
symptoms of internal hemorrhage, combined with the finding of free 
fluid in Douglas' culdesac, will clear up the diagnosis in most cases. 
After rupture has occurred and pelvic peritonitis has set in, the diag- 
nosis is often extremely difficult. A careful history of the case is 
of great value in these cases. Oastler- has directed attention to the 
fact that in cases of pelvic inflammatory disease the uterus is usually 
in retroposition, whereas when ectopic pregnancy is present, it is not 

' Snegireff, G.: Monatsh. f. Geb. u. Gyn., July, 1912, vol. xxxvi, Xo. 1. 
' Oastler, F. R.: Amer. Jour. Obst., January, 1913, p. 158. 



infrequently in anteposition. When the ectopic pregnane^' is ad- 
vanced, the uterus is usuallj' diverted laterally away from the gesta- 

Pelvic inflammatory disease of pyogenic origin can sometimes not 
be differentiated from the gonorrheal form. In general the former 
is more severe and acute, and almost invariably follows the emptying 
of a pregnant uterus or intra-uterine manipulations. The examina- 
tion of these cases usually reveals a marked cellulitis at the base of the 
broad ligament, whereas the tubes may be but little or not at all 
involved. The pyogenic infections arc particularly prone to produce 
ovarian abscesses, while in gonorrhea suppurations of the ovary are 
usually small, somewhat infrequent, and do not occur, as a rule, un- 
less the disease is far advanced. In gonococcal cases, therefore, the 
induration is usually at a somewhat higher level in the pelvis, and 
less dense than when the infection is the result of streptococci or 
staphylococci. In the latter condition uterine bleeding and a hard, 
almost board-like induration at the base of the broad ligaments are 

Appendicitis may be differentiated from gonorrheal infection by 
the history, the location of the pain, and by the fact that pelvic ex- 
amination shows that the uterus and appendages are normal. It 
should be borne in mind that in chronic appendicitis exacerbations are 
especially likely to occur at the menstrual period, as a result of the 
congestion that occurs at this time. Morris' asserts that when the 
vermiform appendix is at fault, a hypersensitive point, one and one- 
half inches to the right of the umbilicus, is usually present, whereas if the 
disorder originates in the pelvis, a corresponding spot of tenderness on 
the opposite side will be present. Actinomycosis of the aj)pendages 
may shimlate gonorrhea so closely that only a careful histologic and 
bacteriologic examination will make differentiation possible. Actino- 
mycosis is, however, a rare disease, and is generally secondary to an 
infection of the gastro-intestinal tract, which usually reaches the 
uterine appendages by perforation and direct extension. The ai> 
pendages are the seat of dense connective-tissue formation, which 
often leads to an erroneous diagnosis of tumor. Not infrequently 
the actinomycotic specimens resemble tuberculous tubes. These fea- 
tures and the absence of gonorrhea in other portions of the genital 
tract should, in most cases, establish the diagnosis. The evidence of 
gonorrhea in the lower genital tract and the bacteriologic demon- 
stration of the specific microorganism alwaj's furnish strong presump- 
tive evidence in cases in which inflannnatory disease is suspected, 

' Morris, R. T.: Amer. Jour. Oljstct., 100!), vol. Ix, No. 2, p. 570. 


although it should be remembered that gonorrhea is a very common 
disease and may, therefore, be combined with other pelvic lesions. 
In a small proportion of cases confrontation may be of value. In 
some instances even the most skilful diagnosticians may be led into 
error. Vague symptoms, inability of the patient to give an intelligent 
history, the absence of proper facilities, faulty preparation for pelvic 
examination, and, finally, and perhaps the most frequent of all causes, 
atypical cases, are all conditions that militate against the formulation 
of a correct diagnosis. 

The cases of gonorrheal pelvic inflammatory disease that are most 
likely to be mistaken for some of the foregoing conditions are usually 
the ones in which immediate operative intervention is required. Thus, 
torsion or rupture of inflammatory adnexa produces symptoms, 
especially if upon the right side, which closely simulate acute ap- 
pendicitis, both of which conditions require immediate operative 

The greatest gentleness should always be obser\'ed when examining 
cases of pelvic inflammatory disease suspected to be of gonococcal 
origin, for rough handling may cause an acute exacerbation. The 
more acute the case is, the greater are the dangers arising from trauma. 
Indeed, a slight rise of temperature following a pelvic examination is 
almost characteristic of this disease, especially if the lesions are sup- 
purative in type. 

Prognosis. — Owing to the great variety of lesions included under 
the term ' ' pelvic inflammatory disease ' ' (metritis, salpingitis, oophoritis, 
pelvic peritonitis, cellulitis, lymphangitis, and parametritis), the ulti- 
mate outcome of untreated cases varies widely in different cases. If pus 
is present, the abscess may rupture into the general peritoneal cavity, 
setting up a diffuse or a local peritonitis, or, in rare instances, even 
a general septicemia. The result of intraperitoneal rupture depends 
largely upon the virulence of the infection and the resistance of the 
patient. (See Chapter XIII.) The abscess may, if situated low 
down in Douglas' culdesac, discharge through the vagina, and leave 
behind a fistulous tract, or it may rupture into the intestine, especially 
the rectum, and produce a temporary or permanent intestinal fistula, 
the pus being discharged through the anus and not infrequently 
causing a proctitis. When the abscess ruptures into the intestine, 
this usually brings about a temporary cessation of symptoms, and in 
rare instances a cure may in this way be established. This is by no 
means an uncommon complication in neglected cases. Alexandre^ 

' Alexandre: Contribution h. I'etude des pyosalpinx spontanement ouvert dans 
rectum, 1911, Destout Atne et Cie., Paris, p. 60. 



has noted this condition frequently. If a proctitis results, the infec- 
tion of the intestine is likely to be extremely chronic. If the abscess 
lies anterior to the uterus, it may burst into the bladder and its con- 
tents be passed through the urethra, thus .setting up a cystitis. 
Cajal' and Kouchner- have reported cases of this condition. In rare 
instances the contents of the inflammatory adnexa may be discharged 
into the uterine cavity. The inflammatory appendage may rupture 
and discharge its contents between the layers of the broad ligament, and 
from here the pus may burrow downward and present in the vagina, or 
it may follow the course of the round ligament and point in the in- 
guinal region. In very exceptional cases, such as those reported by 
Veit^ and by Gaget,'* pus may burrow its way through the abdominal 
wall and in this way produce a tubo-abdominal fistula. Rupture 
in any form is unusual. A pyosalpinx maj' be converted into a hydro- 
salpinx and the tubal contents, becoming sterile, ma}' be graduallj' 
partially or entirelj' absorbed, and in this way the residuum of the 
disease may continue for years without producing severe symptoms. 
Menge^ and others refute, on histologic grounds, the possibility of a 
pyosalpinx ever becoming a hydrosalpinx. That in rare instances 
the contents of a hydrosalpinx maj' become purulent is conceded by 
all observers. 

Mild cases, especially those in which occlusion of the tube does not 
take place, may undergo complete resolution. Bumm" believes that 
so long as the infection is confined to the tubal mucosa a complete 
cure may result, but if the disease extends beyond this point, adhesions 
and other lesions follow. ]VIore commonly, however, these patients 
remain semi-invalids for the remainder of their lives, periods of quies- 
cence being interspersed with acute attacks of pelvic peritonitis. 
Many patients l)ecome neurasthenic. The onset of the menopause is 
often followed by relief: the atrophy of the mucosa and musculature 
of the genital tract, the cessation of the monthly congestion incident 
to menstruation, and the ending of the sexual life of the individual 
all tend to lessen the disease. 

' Cajal, P. R.: La Cliniea modcnia, ,Iuly, 1912, pp. :iG3-:5t)7 and 401-408. 

' Kouchner, M.: Vratchcbnaya Gazeta, April, 1912. 

' Voit: (2uotc<l by Cuin.ston: Amcr. Med., 1902, vol. iv, p. fill. 

* (iaget: J.yon med., 1908, vol. cxi, p. 978. 

' Menge: Cent. f. Gyn., 189.5, vol. xix, p. 799. 

• Hiimin: Therap. d. Gegcnwart, 1909, N'o. I, p. .51. 



It is now well recognized that operative intervention during the 
acute stage of gonorrheal pelvic inflammatory disease is unwise unless 
delay would endanger the life of the patient or if pus is present and 
can be evacuated without traversing the peritoneal cavity. Gonor- 
rheal pelvic inflammatory disease, unlike similar conditions produced 
by the pyogenic microorganism, usually tends to become chronic, 
and the cases in which delay is dangerous to the life of the patient are 
exceptional. The greatest advance that has been made m recent 
years in the treatment of these cases is the adoption of the waiting 
policy advocated by Simpson.' This consists of keeping the patient 
in bed, the judicious use of mild laxatives, the application of either 
cold or heat to the lower abdomen, and the employment of frequent 
copious vaginal irrigations. These are the sheet-anchors of treat- 
ment during the acute stage of gonorrheal pelvic inflanmiatory disease. 
Various other methods, some of which are subsequently described, 
have been recommended, but the value of many of them has not as 
yet been positively proved. It must be remembered that most cases 
of pelvic inflammatory disease will survive the acute stage, even if 
left entirely alone. Any form of treatment that may produce trauma 
is not without danger, and is at least likely to prolong, rather than 
accelerate, the subsidence of the disease. 

Hofmeier^ advises against all forms of purgation, and depends 
solely upon enemata; as has previously been stated, enemata given 
during the course of an acute gonorrhea are not without danger, and, 
in the author's opinion, are contraindicated in the majority of cases. 
During the acute stage of the disease liquid diet should be prescribed, 
and as the acute symptoms begin to subside a light, nourishing, easily 
digested diet, free from alcohol, should be ordered. If, during the acute 
stage, any doubt exists as to the source of the peritonitis, all solid 
food by mouth should be withheld until this point is cleared up. In 
this connection it should be remembered that during the acute stage 
some cases of pelvic peritonitis closely simulate appendicitis, and for 

■ Simpson: Jour. Amer. Med. Assoc, 1909, No. 1"), vol. liii, 11. 117"). 

= Hofmeier: Dculsch. mt'd. Wophenschr., 1909, vol. xxxv, p. 2249. 



this reason every caution should be adopted. Pelvic examinations 
should be as limited in number as possible, and should be gently pe! 
formed, as the dangers to the patient from trauma are very grel 
Cold by means of ice-bags or ice-coils should be applied to thefower 
abdomen and frequent copious cold douches administered Hofmeie, ' 
Bumm,- and Freund'^ are strong advocates of this treatment 

As the acute symptoms begin to subside the application of heat 
to the lower abdomen, together with the frequent use of copious 
hot vagina douches, is of great benefit. Heat may be applied in the 

hecomfoit of the individual patient; or large hot poultices, rubber 
oils contaim,^- hot water, or a hot-water bag may be employed 
n any case the heat should be applied as constantly as possible a 

temperature of 110° to 120° F. being maintained. 1 good worW^g 
ule m this respect is to have the application as hot a.f can be c<^^' 

fortably borne by the patient. Alexandron^ is strongly of the op n- 

cold IS preferable for purposes of stimulation. The majority of the 
German authorities apply cold during the acute state and hea 
VNhen the symptoms become subacute or chronic, the heat frequently 
being applied by means of hot air, in the manner described in a 
previous chapter. Sieber^ employs a modified hot-air apparatus tha't 
provides a constant current of varying temperatures, as demanded 
by the m.hvKlual case. The apparatus consists of a series of ubullr 
celluloid specula which may be connected with an electric heatt^ 
apparatus in such a manner that a current of hot air can be delivered 
at the end of the speculum without unduly heating the latter \ 
temperature of 200° ( '. can be generated. Sieber has usee tie ap 

pamtus with success m a large , ,ber of cases in which pelvic e - 

dates were present. 

Alternate hot and cold applications are recommended by Proch- 

ownick, who advises the application, firs,, of ice to the abdomen 
^owodbymoistheat, and finally ho, air i^^ 

I'M. baths so arranged that ,he hea, can gra.luallv be increased \s 

re^luUon occurs, I,,. .,,na,ion of ,1. ho.-air ba.hs is leng,<l. 

^I'Tf ''"•"•';"^' ;■"-'-'"■'« "'• """ and one-half gallons of sterile 

«at(, o, o, sal, >nln,i.,n, should he adnunis.ered two or three 

' llnlrMchT; l),.,iiscli. i,u;l. \\ „,.|,., |..hmi, .\„. ;j.-, p •>.,.,,, 
■ Hurmn, K.: 'l'li,.r:,[,. ,1. C.VKruxy.. I'.KV.I, \„ 1 ,', ,-,i 
; Kr-..n,l H.: Th.-n,,.. .Monalsl,., .M.-url,, 1!,1I, vol, xxv, X,,. :{, „ ,.57 
^Al,.x; Mo.mts. f. (:,.|,. „.(;,.„„ vol. xii, ,,. inr,. ' 

N.-Imt: .MiincI,, m<..|. Wocl... .Janiii.rv .«), 11112 
IVorhownirk, I..: Mo>m.s. f. ( ;,.|,. „. (Iv,, , l-H)!!, \o -I ,, Vyi 


times daily. In these cases small douches are of little value; indeed, 
Richeloti states that as much as 20 gallons should be employed. If 
the discharge is profuse, the douche may be preceded by an irrigation 
with a quart of hot water to which a dram of A. B. C. douche powder 
or other mild antiseptic has been added. It is important that the 
douche be given slowly and that no force be used. It will usually be 
found that the much hotter fluid may be employed if the temperature 
is raised gradually than if very hot water is used at the beginning. 
The same caution should be employed in the administration of these 
douches as has been described under the treatment of acute metritis. 
If the pain is very severe and is not relieved by the application of 
either heat or cold, the administration of some one of the opium 
derivatives may become necessary, but these should be exhibited as 
sparingly as possible. Schindler- contends that to account for the 
large proportion of gonorrheal infections above the cervix the uterus 
must possess some active movements, the gonococcus, as is well known, 
being non-motile. This observer believes these movements are invol- 
untary and not influenced by the central nervous sj^stem. The 
administration of atropin paralyzes the automatic movements, and 
for this reason he recommends its use during the acute stage of all 
gonorrheal infections. 

During the acute stage the placing of the patient in the upright 
Fowler position is of great advantage, not only for the treatment of 
the peritonitis, but it helps very materially in draining the uterus, 
which is usually the seat of an endometritis or a metritis. In cases 
that present unusually severe symptoms of pelvic peritonitis entero- 
clysis, as suggested by Murphy, may be employed with advantage. 
To guard against infection of the rectum the perineum and external 
genitalia should be thoroughly wiped with absorbent cotton soake(^ I 
in 1 : 1000 bichlorid solution. A tampon should be inserted in tha 
vagina before the rectal tube is introduced. Additional medicina 
treatment is rarely indicated. 

The advantages to be derived from the pallia ti\-e treatment 
over immediate operative intervention are manifold. In itself, gon- 
orrhea is rarely a fatal disease. The results of this plan of treatment 
are generally most satisfactory. Large, painful tubes resolve them- 
selves into small adherent organs, the ovarian symptoms tend to 
subside, and tender, adherent masses finally disappear, ^\1lile sur- 
gical intervention is not indicated in the great majority of cases ol 
acute gonorrheal pelvic inflammatory disease, nevertheless the patients 

' Richelot: La Gyn^cologie, May, 1909. 

- Schindler, C: Arch. f. Gyn., BerUn, 1909, vol. Ixxxvii, p. 607. 


are essentially surgical subjects and should be carefully guarded, as 
complications may arise that will demand immediate operation. If 
pus forms and can be evacuated without danger of infecting the 
peritoneal cavit}', this should be done at once, and in these cases 
the incision should be a large one — at least 5 to 8 cm. in length. 
Boldt' recommends an incision large enough to admit the hand. 
With the rare exception of rupture or torsion of an inflamed uterine 
appendage or the development of general peritonitis, these are prac- 
tically the only indications for operative intervention during the acute 

Kuhn- suggests the treatment of pelvic inflammatory diseases 
with injections of normal salt solution into the rectum. His plan 
differs from the ^Nlurphy-Ochsner method. Kuhn suggests that the 
rectum be distended at six-hour intervals with from 1 to 4 pints of the 
solution at a temperature of 105° F., increasing the quantity gradually 
as tolerance to the larger amount is established. He claims for the 
method that it produces hyperemia, hastens the destruction of the 
infecting organi.sms, induces absorption, prevents the formation of 
adhesions, stimulates the emunctories, and relieves pain. The 
method can hardly be recommended, at least as a routine procedure, 
as the discomfort caused to the patient is considerable and the dangers 
of infection of the rectum are great. Unless the treatment is applied 
with the utmost care, the danger from overdistention of the rectum 
and the possibility of lighting up a chronic inflammatory disease by 
the trauma incident to the distention, are to be feared. Flatau' rec- 
ommends applying heat by means of the "pelvitherm" (Heinroth 
Slanger, Ulm a.D., Germany), which raises the temperature in the 
female pelvis to about 40° C. (104° F.). Cheron' recommends the 
use of radium in the treatment of chronic adnexitis and peri-adnexitis, 
on account of its atrophic action on the ovaries. The treatment lasts 
from one to six weeks. This author believes that radium therapy 
alone will cure many cases, and that it is an excellent preliminary to, 
and adjunct in, the treatment of most cases in which surgical inter- 
vention is necessary. The radium is applied in silver tubes 0.5 mm. 
in diameter. These are introduced into the uterine cavity under 
a.septic precautions. Fabre' asserts that radium gi\-os marked relief 
froni pain and frecjucntly softens indurated areas of cellulitis. Coni- 

' Uoldl, II. .1.: .Jour. .Vmcr. Mori. .V.ssoc, July 1:5, 1912, p. l():i. 
' Kuhn, J. !■'.: Texas State .lour. .Mod., December, 1911, vol. vii, No. S, 
• Flatau, S.: Munch, raeil. Woch., 1900, No. 2. 

*('heron, II.: Hi-v. mens, de gj-ii. d'obst. et do paed., December, 1911; also La Ob- 
8t6trif(ue, .November, 1909. 

' Fabre: .\rcli. Roentgen Kays, November, 1910, p. 228. 


plete cures usually require prolonged treatment. Jacobs' and Bar- 
cat- also recommend this form of treatment in the chronic stage of 
pelvic inflammatory disease. The last-named author's paper con- 
tains a review of the recent literature on this subject. Menge^ men- 
tions that in the Heidelberg Gynecological Clinic old gonorrheal 
adnexitis cases that are complicated by profuse bleeding and dis- 
charge are treated with the x-ray. The belief of some authors that 
this treatment will cause an exacerbation of the infection is com- 
bated by Menge, who reports excellent results from its employment. 

As the acute symptoms subside hot salt sitz-baths or hot general 
baths can often be given with advantage. Freund^ has shown that 
when hot sitz-baths are given, the vaginal temperature is often raised 
as much as 5° to 10° F. At this stage Prochownick" and others rec- 
ommend the use of the mercury colpeurynter. This is left in place 
at first for two or three hours daily. The period of retention is grad- 
ually increased, as is the size of the colpeurynter, and toward the 
latter stages of the treatment the instrument can usually be retained 
without discomfort overnight. A hard-rubber cylinder has some- 
times been substituted for the colpeurynter. At this stage Hofmeier* 
applies heat by means of a thermophile. Sellheim^ applies heat by 
means of an electric current, one electrode being placed over the 
lower abdomen and the other in the vagina, the pelvic temperature 
being raised to about 40° or 41° C. (104°-105° F). This produces 
first a hyperemia, then an anemia, and finally a cyanosis of the vaginal 
mucous membfane. This writer prefers this method of applying heat, 
for by its employment it is possible accurately to measure and control 
the heat. The author believes that the indiscriminate application of 
electricity to cases of pelvic inflammatory disease is not without 
danger, as is instanced by the case of rupture of a pyosalpinx during 
such treatment reported by Fisher.* 

Freund' recommends congestion of the pelvic organs, as advocated 
by Bier,'" the suction apparatus being placed over the lower abdomen. 
He also has the patients assume the knee-chest posture for ten minutes 
twice daily, having found that this treatment lowers the temperature 

' Jacob.?: La Radium en Gynecologie, 1911. 

= Barcat: Prec6s de radium therapio, Paris, 1912. 

' Menge, K.: Hand. d. Geschlechtskrankheiten, Vicima, 1910. 

■" Freund, H.: Therap. Monatsh., March, 1911, vol. xxv, No. 3, p. l.'J". 

' Prochowniek, L.: Monats. f. Geb. u. Gyn., 1909, vol. xxix, p. 45.3. 

' Hofmeier: Deutsch. med. Woch., 1909, No. 35, p. 2249. 

' Sellheim: Monats. f. Geb. u. Gyn., May, 1909, vol. xxxi, p. 92. 

« Fisher, .1. M.: Trans. Phila. Obstet. Soc, 1911. 

» Freund, H.: Therap. Monatsh., March, 1911, vol. xxv, No. 3, p. 157. 

'" Bier: Hyperamie als Heilmittel, fifth edition, 1907. 


of the vagina 4° to 7° F. and sometimes more. This position also tends 
to prevent the occurrence of extreme retrodisplacement of the uterus. 
While the patients are in bed, and after the disappearance of the fever, 
general massage is beneficial, but care must be taken that no trauma 
is inflicted on the abdomen. For this reason the massage should be 
administered only by a skilled and specially instructed attendant. 

After about the second or third week, when the temperature and 
pulse are normal, it- is usually advisable to get the patient out of bed 
and into the open air. Indeed, when pos.sible, marked improvement 
is usually shown, even in bed patients, when they can be kept in the 
open air, and it seems probable that this adjunct to the treatment of 
pelvic inflammatory disease has been much neglected in the past. 
Stone' and Young and Williams- have strongly recommended this 
form of treatment. These writers state that, by this means, their 
mortality in severe cases of puerperal sepsis have been reduced nearly 
20 per cent. They believe that sunlight is nearly as important as 
fresh air, and think that the open-air treatment is beneficial largely 
because of the fact that it quickly increases the amount of hemoglobin. 
Watkins^ is a firm believer in this mode of treatment. The author's 
experience has been that patients do far better in the open air than 
when confined to a room or ward,, no matter how well ventilated the 
latter maj- be. Yan Oordt^ has demonstrated, by his extensive ex- 
periments, that patients who are exposed to low temperatures, either 
in a nude state or scantily clothed, show a leukocytosis that is pro- 
duced by thermotaxis. The leukocytosis lasts as long as the exposure 
to cold is continued. Lenkei'' found that in his researches cold air 
produced a 9.S per cent, increase of leukocytes. Orr," however, found 
that in afebrile patients in whom the face only was exposed there was 
no constant change in the leukocytes. 

The general plan of treatment should be a building-up and strength- 
ening process. Mild laxatives and tonics containing iron or arsenic 
may be indicated. All exercise should be restricted, and sexual inter- 
course interdicted. The dangers of reinfection from a husband who 
has an uncured gonorrhea and of trauma incident to coitus are very 
real and ha\'e been extensi\ely dwelt upon by Boldt" in a recent article. 

' Si.iiic-: Mill. I^oronl. 1907. vol. Ixxi, p. L'Ki. 

• VouiiK. K. H., an.l Williams, .1. 'I'.: H.isloii Mc.l, uii.l Siirn .Imir.. Man-I, 11, I'.tl.', 
p. 4().V 

' Wat kins, T. J.: Personal coinmiinicatioii. 

'Van f)or<lt: Zcit. f. (liiilotisclio ii. phy.sikali.schr 'I'licrapic 1<.H).')-(1(;, vol. i\, p. :i:{S. 

' Lcnkoi: Vrsicr riicil. Cliir., May, 1910, vol. xlvi, No. 20. 

• Orr, T. (;.: Amcr. .lour. .Med. Sci., AukusI, 1912, p. 2:«. 

' Holdl, H. .!.: .lour. Amcr. .Med. A.ssoc. .luly Kl, 1912, p. 100. 


The douches should bo continued, and local treatment, consisting of the 
insertion of a vaginal tampon saturated with ichthyol or glycerin, or one 
of the other remedies recommended in the treatment of metritis, should 
be applied once or twice a week. The tampon should be left in place 
for from ten to sixteen hours, and on its withdrawal a hot vaginal irriga- 
tion should be given. On the days when the tampons are inserted all 
other forms of local treatment should be discontinued. If, during the 
course of this treatment, the temperature rises to 100° F., or other 
symptoms indicative of a recurrence of the acute condition appear, 
the patient should return to bed and the treatment previously out- 
lined for the acute stage of the disease administered. During the 
course of the palliative treatment it is of the utmost importance that 
all local measures be applied with great gentleness, as trauma at this 
stage is likely to light up the acute condition. 

With the palliative method of treatment a certain percentage of 
cases will be spared any form of operative intervention. Before 
entering into a discussion of the permanent efficiency of this treat- 
ment, however, it is important first to define what is meant by a cure, 
as a complete anatomic cure is, in the majority of cases, impossible. 
In this connection Prochownick^ states that when a cure is permanent 
the patient must be able to take up her mode of life or occupation; 
her sexual organs and the neighboring intestines must functionate 
regularly and painlessly. Prochownick's statistics are of particular 
value; his hospital is so richly endowed that patients are allowed to 
remain indefinitely, and, if necessary, they are sent to the seashore- 
at the hospital's expense. In compiling his statistics he has included 
no cases that have been treated later than 1905, so that it may be 
inferred that all recurrences have been noted. It is, of course, im- 
possible in this connection positively to exclude all forms of infection 
other than gonorrheal. In Prochownick's series no tuberculous cases 
are admitted. He, however, includes in his list of cases receiving 
palliative treatment those in which pus collections in either the tubes 
or the ovaries were evacuated extraperitoneally, and in which no 
organs were removed. Of 420 cases, 160, or 38 per cent., were per- 
manent cures. Of these, 70 per cent, were treated for not less than 
four weeks, whereas many were treated for five or six weeks in the 
hosiptal and were then sent to a sanatorium for three or four weeks 
more. Of the 160 cases, 10 per cent, had pus collections which were 
evacuated, and these usually required treatment for two or three 
weeks longer than those in which no operation was necessary. Of the 
160 cases, 85, or 55 per cent., remained well after one course of treat- 
' Prochownick, L.: Monats. f. Gfb. u. Gyn., 1909, No. 20, p. 453. 


nient. Of this number 14 subsequenth' gave birth to children and 
3 aborted. After a second course of treatment 27 remained well and 
3 became pregnant, of which 1 aborted. In other words, 1 in every 
8 cases cured became pregnant. In this connection it should be re- 
membered that many of these patients were not married and that 
others were not young, so that if the statistics covered only those 
patients in which impregnation was likely to occur, the proportion 
would probably be much higher. Of these 160 cases 10 finally re- 
quired operation for relief of adhesions, but it was not necessary, 
however, to remove any organs. These 10 operations occurred at 
varying intervals of from three to five years after the first treatment. 
One of these patients subsequently gave birth to a child. The number 
of permanent cures without any operative interference whatever was 
80, or 19 per cent., of 420 cases. In Prochownick's series of cases no 
deaths resulted from the palliative treatment. In contradistinction 
to the foregoing statistics, Henkel' states that in from 80 to 90 per 
cent, of all inflammatory affections of the adnexa "subjective healing" 
occurs following judicious non-operative treatment. Olshausen- is 
a firm believer in the palliative treatment, and in his clinic operations 
on inflamed adnexa arc, if possible, deferred until nine months after 
the occurrence of the infection,- and are then performed when the 
temperature is normal. 

Ooth^ has recently reported excellent results in a series of 700 
cases of pelvic inflammatory disease treated by the palliative method 
in Szabo's clinic. The treatment consisted in i-est in bed, the applica- 
tion of ice-bags over the lower abdomen, and (•(i])ious vaginal irriga- 
tions of cold sterile water — at a temperature of 10° or 11° C. (50° to 
51° F.) — during the acute stage. As soon as the temperature and 
pulse became normal and the pnin had subsided hot applications were 
substituted for the cold, ;iii(l tampons containing from 10 to 20 per 
cent, ichthj'ol were introdiiced two or three times a week. When 
the presence of gonococci could be demonstrated in the discharge, 
I)r()targoI in 20 per cent, solution was employed in place of the ichthyol. 
Pelvic examinations wei'c made once a week. Preparations of iron 
were employed as tonics, and morphin was given to control ])ain and 
ergotin to check bleeding. The cures consumed on an average fifty- 
six days, the minimum being eighteen days, and the maximum, two 
hundred and thirty days, (loth believes that febrile cases respond 
more readily than afebrile ones to treatment. 

' llcnkcl: (2iioH-(l by Kscli: Zi-it. f. (iel). u. (iyn-, Ii»l)7, vol. lix, No. I. 
■ OlNhaiiscn: Quoted l>y Kseh: Zcit. f. Gcb. ii. (iyn., li)07, vol. lix, .No. 1. 
Mlolh: Anil. f. Cyn., vol. .\cii, No. 2, \>. :5()0. 


De Rouville' reports the results obtained in a series of 40 cases 
treated by the palhative treatment. Of these, 32 were cured and 3 
subsequently became pregnant. Ciriffith- reports the results obtained 
by the palliative treatment in 48 cases. No deaths occurred, and 
the local conditions were much improved. Topfer^ strongly urges 
palliative treatment in these cases. 

The chief difficulty attendant upon the form of treatment just 
outlined is the amount of time that is required. During the acute 
stage the patient should certainly be in a hospital. After two or 
three weeks the condition is generally such that the remainder of the 
treatment can be carried out in the home, under the supervision of 
the family physician. Before such patients are discharged from the 
hospital they should be informed of the nature and probable course 
of their disease, and a careful bimanual examination should be made 
in order to ascertain the exact pelvic condition. They should be 
instructed regarding their mode of life and the importance of treat- 
ment; sexual intercourse should be interdicted. Whenever possible, 
the entire course of treatment is best carried out in a hospital or sana- 
torium, for in spite of the most careful instructions, these patients, 
when at home, after the pain has subsided frequently commit in- 
discretions in diet, neglect their treatment, or indulge in sexual inter- 
course, oftentimes with a chronically infected husband, and as a 
result, relapses occur. The patient's social status is of importance in 
this connection. As has been pointed out by de Rouville,'' women 
who have to work hard are more prone to develop a recurrence after 
palliative treatment than are their more well-to-do sisters. 

The author believes that, in spite of any form of palliative treat- 
ment that may be adopted, the majority of gonococcal inflammations 
of the appendages will ultimately require operative intervention; 
nevertheless, he is of the opinion that a fair trial of such treatment 
should be made in each case, and that by this method better operative 
results will be obtained than if immediate operation were undertaken. 
Under the palhative treatment the infective microorganisms in many 
cases become innocuous, and the uterus and adnexa again approach 
the normal. Nature has been allowed to cure as much of the pathology 
as possible, and when the abdomen is opened, one can more easily 
decide upon the most suitable operation for the individual case. There 
can be no doubt that following the expectant treatment a greater 

' lie Rouville; Annal. de Gyn. et d'Obst., (Jctobor, 1910. 

2 Griffith, W. S. A.: Brit. Med. Jour., October 26, 1912, p. llOli. 

'Topfor: Rerlin. klin. Woch., September 2, 1912. 

» de Kouvillc: Annal. de Gyn. et d'Obst., October, 1910. 



number of cases will be rendered suitable for conser^•ative operations 
than if they were at once subjected to surgical treatment during the 
acute stage. Furthermore, the mortality will be reduced. Following 
this plan Simpson' has reported 475 consecutive abdominal sections 
for inflammatorj' lesions of tubal origin, with only 4 deaths. In 
addition to the reduced mortality, the postoperative results will be 
improved. It will be found that the operation can be performed with 
greater speed and less anesthetic will be required, and fewer hernias 
and a lessened proportion of operative infections and consequent 
postoperative adhesions will be encountered. 

By converting acute inflammatory infections of pelvic origin into 
aseptic lesions the mortality will be reduced and the postoperative re- 
sults vastly improved. Undoubtedly, occasionally cases will be en- 
countered that will not improve under expectant treatment, but the 
more carefully these cases are studied, the fewer will be the number 
requiring immediate operative intervention. Sanger, the skilled pa- 
thologist and gynecologist par excellence, was the first to lay stress 
on the fact that chronically adherent appendages were not the seat of 
infection, but merely the derelicts of the gonococcal storm. Accuracy 
of diagnosis is the necessary adjunct to this treatment, and only by 
its aid can the surgeon successfully adopt the waiting policy. Bumm- 
is of the opinion that the majority of cases of postoperative peritonitis 
result from too earh' operation. He thinks it best to wait until the 
infection becomes localized, as sometimes there is a mixed infection, 
and early operation on such cases frequently results in fatal perito- 
nitis. Thaler,'' after having reviewed 6179 cases of jjelvic inflammatory 
disease at Schauta's clinic, concludes that operative treatment is indi- 
cated only after palliative treatment has failed, except in cases where 
it is necessary to evacuate pus. 

.Vuihorn' reports an interesting series of treatments from Zweifel's 
clinic. In 123 cases of adnexitis that were chiefly gonococcal in 
type, and that varied in degree from slight inflammations to large 
tubal abscesses, he injected silver solutions into the uterine cavity. 
Some years previously Zweifel had carried out a series of experiments 
which consisted of the injection of methylene-blue solution into the 
uterine cavity, and found that in every case the blue was carried out 
into the tubes.' Aulhorn'-s" treatment consisted of the following: 

' Simpson: .Jour. .\mer. Mfd. .A.s.soc, li)()9. No. 1.'), vol. liii, p. 117.') 

' Humin: Tlicnip. li. (Icgcrivvart. 1909, No. 1, p. .")1. 

'Thaler, II.: Arcli, f. Cyn., Horliii. vol. xciii, No. :{, p. ll.i. 

' .\iilliorn: .\rcli. f. (!yii., vol. xv. No. 2, p. 2i:i. 

'In II oasos, S of which were inflamiiialory and in .'J of which the- luhc.-i were normal, 
I he author ha.s injected either met hyleiic-hlue or .starch solution into the uterine cavity. 
In tione ha.s it been pos.sihic to clerri'oM.-tnitc llic iTi:ileri:il In the lulics. 

'■ .Vuihorn: A,or. rii. 


No injections were made during the acute stage. The patients were 
kept in bed. The injections were made up of a colloidal silver, such 
as argentamin, or a silver phosphate, often ethylendiamin, in 2 per 
cent, solution. One or 1.5 c.c. was injected at the first treatment. 
At subsequent treatments this amount was increased to 2.5 c.c. The 
treatments were given 6 times a week. At first considerable pain 
followed the injections. This lasted for one or two hours. Of 123 
cases, 108, or 88 per cent., were cured of all symptoms, 7 improved, 
whereas in 8 little or no benefit was derived. Examined objectively, 
a cure was effected in 89, or 72 per cent., marked improvement in 16, 
and little or no imj^rovement in 18. Before treatment, 60 of these 
cases had palpable tubal abscesses the size of a hen's egg or larger; 
46 of these were objectively cured. Cures required from 15 to 40 in- 
jections, and extended over a period of from four to six weeks. During 
the course of treatment many cases suffered from menorrhagia. All 
treatments were discontinued during menstruation. Aulhorn^ has 
employed intra-uterine injections over 3500 times, and has never seen 
a case in which ill effects resulted. The author is of the opinion that 
this form of treatment requires more confirmatory experiments be- 
fore its adoption could be generally recommended, and that it is 
quite probable Aulhorn's results would have been quite as good if no 
intra-uterine injections had been given. 

Not infrequently cases are seen in which the question arises as 
to whether a hysterectomy and a bilateral salpingo-oophorectomy 
shall be done and the patient relieved of her present trouble, or whether 
it is advisable to perform one of the conservative operations. To de- 
cide this question many factors must be taken into consideration — 
the age of the patient, whether she has a number of children, whether 
she is particularly desirous of maternity, whether she has to support 
herself by hard manual labor, her social status, and, lastly and almost 
of paramount importance, the temperament of the individual. Even 
after a careful study of each case and a review of all the points bear- 
ing on it it will in not a few cases be difficult to decide what course 
will be best for the ultimate welfare of the patient. The author 
believes that, when not contraindicated, a period of at least from 
four to six weeks should be allowed to elapse during which the tempera- 
ture and the blood-count remain normal, before operation for intra- 
peritoneal gonorrheal pelvic lesions is undertaken; and that preliminary 
palliative treatment should be given to all cases before operation. 

' Aulliorn : Loc. cit. 


WTien possible, it is best to operate about a week or ten days after 
menstruation has ceased, as at this time less congestion is present and 
infection is probably somewhat less likely to occur. It has been amply 
shown, bj^ both bacteriologic and clinical investigation, that more gono- 
cocci and other organisms, in cases of mixed infection, are present in 
the discharge from the genital tract at and immediately subsequent to 
menstruation, so that this time would seem, at least theoreticallj-, less 
favorable than during the interval period. Hyde,^ however, believes 
that work can be done on these cases as satisfactorily during menstrua- 
tion as at any other time. Lovrich- states that during the menstrual 
congestion it is much harder to overcome hemorrhages; he, therefore, 
operates during menstruation only in cases where postponement is 


The advantages to be derived from conser\'ative peh'ic surgery 
are now well recognized. For many years conservative surgery of 
the pelvic organs was looked upon somewhat doubtfully, for a certain 
proportion of the cases were not subjectively cured, and in some 
instances required secondar}' operations. As has previously been 
pointed out, preliminary treatment greatly lessens this proportion. 
It is a significant fact that those who have most vigorously attacked 
this form of conservative surgery are the operators who have not 
followed the after-histories of their cases, and who base their asser- 
tions on general grounds that are not borne out by accurate data. 
Polk,' in this country; Pozzi,'' in France; and IMartin,* in Germany, 
were among the early advocates of conservative surgery in cases of 
gonorrheal pelvic inflammatory disease. Conservative surgery of the 
pelvic organs may be divided into operations on the tubes, ovaries, 
or uterus. 


In the author's opinion, tliis form of surgery has a very limited 

field. The presence of pus in the tube is an absolute indication for 

its removal in all cases. Small adherent tubes, in which the abdominal 

ostia are closed, should also be excised. The only cases in which a 

' Hydo, C. R.: Amer. .lour. Surg., April, lill2, p. i:«. 

'Lovrich, J.: The Sixth Intornational ( "()ngrcs.s of Obstotrici.ins ami (!yiicc<)logi.sls, 
Berlin, ScptPinbcr 9 to 13, 1912; Surg., Gyn. and Olxst., Decpinljpr, 1912, p. 7 t:{. 
> Polk, .\. M.: New York Med. Record, September 18, 1880. 
* Pozzi: Rev. de Gyn., 1S97, vol. i, No. 3. 
' Martin, A.: Volkniaiin's .Simiiil. klin. Vortragc, 1889, No. 343. 


salpingostomy is ever justifiable is in old, non-active hydrosalpinges, 
and in those eases of tubal occlusion or phimosis resulting from extra- 
tubal inflammation, such as sometimes results from appendicitis or 
ectopic pregnancies. The latter cases are obviously rarely gonococcal 
in origin. The tubal contents being sterile and the tubal mucosa 
normal, except for the results of intratubal pressure, these cases offer 
the most favorable results from salpingostomy. 

One of the chief defects of a simple salpingostomy is that in a 
great number of cases the intramural portion of the tube, as well as 
the abdominal ostium, is occluded. To overcome this, hysterosal- 
pingostomy has been devised. The usual after-histories of all forms 
of salpingostomy show that the newly formed ostia close and a 
recurrence of symptoms takes place, and this despite the utmost care 
displayed in performing the operation. The percentage of cases in 
which pregnancy takes place after salpingostomy has been performed 
is small, whereas recurrences are frequent. Turk' reports 8 cases in 
which salpingostomy was performed, 2 of which subsequently be- 
came pregnant. With one exception the cases, however, are not 
recorded in detail, and the condition of the opposite tube is not stated. 

Gellhorn,'- Kehrer,-^ ^Nlartin,^ Alackenrodt,^ Skutsch,^ Gersuny,' 
Pozzi,** and Stone^ have all reported pregnancies following salpingos- 
tomy, while Polk,'" Morris," Bonifield,'- Polak'^ (3 cases) , and the author 
have had cases of pregnancy follow resection of a tube. Mc Arthur'^ 
states that he has performed the operation of salpingostomy very fre- 
quently, and cannot recall a single successful physiologic result. Small 
or normal sized tubes, in which the abdominal ostia are open, may be 
freed of adhesions, but better results will usually be obtained by their 
removal. The author believes that unless there is some indication 
making maternity especially desirable, a conservative operation on the 
tubes should not be performed, and, when possible, the patient 

' Turk, R. C: New York Med. Jour., 1909, vol. Ixxxix, p. 1193. 

■ Gellhorn, G.: Surg., Gyn., and, July, 19U, p. 10. 

' Kehrer, E.: Monats. f. Geb. u. Gyn., October, 1909. 

' Martin: Quoted by Kehrer, E.: Loc. cit. 

'Mackenrodt: Quoted by Kehi-er, E. : Loc. cil. 

"Skutsch: Quoted by Prochownik, L.: Monats. f. Geb. u. Gyn., 1900, vol. .xxi.x, 
p. 4.53. 

'Gersuny: Quoted by Prochownik: Loc. cil. 

'Pozzi: Quoted by Prochownik: Loc. cil. 

' Stone: The Virginia Med. Semi-Monthly, June 7, 1912, p. 10.5. 

'" Polk, W. M.: Quoted by Kelly, H.: Operative Gyn., first cd., 1889, p. 192. 

'• Morri.«, L. C: Amer. Jour. Obst., 1910, vol. Ixii. 

" Bonifield, C. L.: Amer. Jour. Obst., 1903, p. 6.5S. 

'' Polak, J. O.: Amer. Jour. Obst., 1910, vol. Ixii, p. 676. 

'< McArthur, A. N.: Australian Med. Jour., February 12, 1912, p. 333. 


should be advised as to the nature of her condition and the Hkehhood 
of faihire, and should herself be the one to decide the nature of the 

Uffreduzzi' has reported the results of a series of experiments 
performed for the purpose of ascertaining the ultimate results of 
salpingostomy, Clado's tubo-ovarian anastomosis, and Gersuny and 
Doderlein's utero-ovarian anastomosis being employed. In this series 
19 animals were utilized, and in all the results were disappointing, 
as far as the possibility of subsequent pregnancy was concerned. 

The general unsatisfactory results obtained by conservative tubal 
surgery may be attributed to the fact that the great majority of tubal 
inflammations are of gonococcal origin. One of the chief characteris- 
tics of the gonococcus is its persistence. After having once established 
itself in a location suitable for its growth, it is practically ineradic- 
able the affected area is so situated as to be easil^y accessi- 
ble to local treatment. It has been shown that gonococci may lie 
dormant in the tube for prolonged periods, and this persistence of 
the organism accounts for many of the failures in conservative surgery. 

The brighter side of conservative tubal surgery is observed when 
we consider those cases in which a normal tube exists on one side and 
a diseased tube on the other. In. these cases the normal tube should 
be disturbed as little as possible. Excellent results have been ob- 
tained l)j' this treatment, and comparatively few such cases require 
a secondary operation. When it is decided to perform a salpingec- 
tomy, the radical operation, i. e., the removal of a wedge-shaped 
portion of the uterine cornua, together with the outer two-thirds or 
three-fourths of the intramural part of the tube, should be the opera- 
tion of choice. The writer has recently seen two cases of cornual 
abscess and one case of intramural tubal pregnancy occurring in the 
stump left by a previous salpingectomy, when the intramural ])ortion 
of the lube hail not Ix-cn excised. 

The ovary is tlic analogue of the testicle, and is nearly or (juite 
as important as that organ. For this reason considerable surgical 
risks are justifiable for its preservation. The removal of diseased 
tubes merely renders the patient sterile, a condition that usually 
exists before operation is undertaken ; whereas a double oophorectomy, 
at least in a certain i)roportion of cases, converts a previously normal 
woman into a hopeless neurasthenic. The sudden onset of tlie arti- 
ficial menopause, with its accom])anying nervous symptoms, the in- 

' I'lTri'iluzzi O.: Aiuiali di oslcliiciiic ninccDloiiinJ'.ll 1, vol, ii. 


ability successfully to fulfil the marital relations, together with the 
mental effect produced by the cessation of the menses, and the knowl- 
edge that is more or less suddenly and forcilsly brought to the wo- 
man's mind that she is prematurely aged, and that the possibihties 
of maternity have forever been removed — all these tend to render the 
patient miserable. There is no doubt that the age at which a double 
oophorectomy is performed, together with the individual temperament 
of the patient, plays a very decided part in the after-history of these 
cases, and that some women bear the results of the operation much 
better than do others. Too much importance, however, cannot be 
placed on the age, as Peterson^ has shown that some of the most 
serious after-effects follow the artificial production of the menopause 
in women between forty and forty-five years of age. Although some 
patients may be relatively little affected by the operation, more than 
half will suffer very severely, and in a definite proportion the result 
will be little short of appalling. 

One has only to follow the after-histories of a few cases to be 
convinced of the disastrous effects of a double oophorectomj^ In a 
large series of cases in which both ovaries were removed Giles- found 
that the flushes and other symptoms of the artificial menopause 
continued for from three to four years in most cases, and in some 
individuals persisted for ten years. Severe mental depression occurs 
in from 10 per cent, to 33 per cent, of cases, whereas of 157 cases, 2 
became insane. Sex instinct is entirely abolished in 16 per cent., and 
it is only a matter of time before this is entirely lost. It has been 
clahiied that the preservation of one ovary is sufficient. This state- 
ment is based on the principle that "half a loaf is better than no 
bread." The patients upon whom a unilateral oophorectomy is per- 
formed often menstruate scantily and undergo an early menopause. 

Dickinson^ states that a review of 200 cases in which conservation 
of one or both ovaries has been practised shows that even when the 
uterus has been removed, not more than 20 per cent, of the patients 
suffer from the surgical menopause. His results were better when 
both ovaries were spared than when one was removed, and that in 
the latter class of cases the menopause was likely to occur somewhat 
earlier than in the normal woman. Giles,'' after a careful review of 
1000 abdominal sections, of which 50 were unilateral salpingo-oophor- 
ectomies for pelvic inflammatory disease, concludes that the removal 

' Peterson, R.: Amer. Jour. Obst., May, 1908. 

' Giles, A. E.: Jour. Obst. and Gyn. of Brit. Emp., March and April, 1910. 

' Dickinson, R. L.: Trans. Amer. Gyn. Soc, vol. xxxvi, p. .324. 

' Giles, A. E.: Jour. Obst. and Gyn. of Brit. Emp., March and April, 1910. 


of one ovary causes irregularities, diniiiiution, or cessation of the men- 
strual flow in a definite proportion of cases (16 per cent, of his), and 
that in a somewhat smaller proportion (12 per cent.) the sexual desire 
is lessened or abolished. In 133 of our own cases at the University 
Hospital in which one ovary had been removed, menstruation was 
diminished or irregular in 50. 

Carmichael,' Valtorta,- and Mcllroy'' found that in animal ex- 
perimentation, when one ovary was excised, there was a permanent 
compensatory hypertrophj^ of the other, and this doubtless takes 
place to a certain extent in women and may account for some of the 
irregular bleedings that occasionally follow unilateral oophorectom}\ 
Mcllroy also states that the uterine function and nutrition seem to 
depend upon the ovarian secretion, as atrophy occurred after bilateral 
oophorectomy. The myometrium was the first to show atrophj-; 
the glands of the mucosa disappeared graduallj% and the surface 
epithelium retained its normal condition the longest. The mam- 
mary glands and the external genitalia were likewise invariably atro- 
phied. Atrophic changes in the uterus following the removal of the 
ovaries prior to the establishment of the normal menopause have been 
observed by Knauer,'* Gigorieff,^ Ribbert,^ HalbanJ Rubinstein,^ and 
many others. 

A further comi)arison between the tube and ovary shows that the 
essential structure of the tube, i. e., the mucosa, is chiefly involved, 
whereas in the ovary, at least in gonococcal infections, the important 
constituents are destroyed only in the last stages of the disease. A 
peri-oophoritis is the most frequent accompaniment of a pyosalpinx, 
and usually only in the advanced cases is an actual oophoritis present. 
For this reason, when the primary source of the infection is removed, 
the ovary is prone to undergo resolution. In examining the his- 
tologic diagnoses of 490 ovaries removed consecutively for pelvic 
inflammatory disease at the University Hospital, the author found 
260 of peri-oophoritis, thus showing the relative frequency' of 
this condition. 

In this connection it must be reinoml)ored that this is a conserva- 

' Carmichiiol, K. S.: Kdinhuriih Mc.l. Joui'., .\I;irch, V.)Od, p. 242. 

• Valtorta, F.: Ann. di ostot. u gin., .July, liUl. 

* Mcllroy: Jour. Olwt. and Gyn. of Brit. Enip., July, 1912. 

« Knaucr: Zent. f. (lyn., 1890, vol. xx, No. 2; also ibi'l., 189S, vol. xxii, p. 21)1; also 
Wien. klin. Woch., 1.S99, vol. xii; also .Vrch. f. (!yn., 1900, vol. ix; also Stevens' Jour, of 
Obst. and Gyn., January, 1904, vol. v. 

' GigoricfT: Zent. f. Gyn., 1897, vol. xxi. 

•Ribbert: Arch. f. Enlwiok.-Mechanik, 1898, vol. vii. 

' Halban: Monats. f. Geb. u. Gyn., vol. xii, No. 4, p. 49ii. 

•Kubinslciii, II.: St. IVtershurK. mod. Woch., 1899, No. 31, p. 281. 


tive clinic, and while probably all, or nearly all, the ovaries the seat 
of advanced inflammatory lesions have been removed, many organs 
that would have been classified under the head of peri-oophoritis have 
been spared, so that the relative proportion of peri-oophoritis and 
oophoritis is even more marked than would appear from the foregoing 
figures. It is impossible to formulate any hard and fast rules govern- 
ing the removal or conservation of an ovary, as this is dependent upon 
so many factors. Polak' emphasizes the fact that an enlarged ovary 
is not necessarily a diseased one. 



As has been repeatedly stated elsewhere, successful ovarian con- 
servation after salpingectomy is dependent chiefly upon three factors: 
(1) The surgical judgment of the operator — it is obviously unwise 
to conserve an ovary in which the disease is of such a character as 
to make it certain that it will continue to progress after removal of 
the tube. (2) Non-interference with the blood-supply of the ovary. 
(3) Maintaining the ovary in a favorable position, preferably in its 
normal situation. 

Condition of the Ovary. — The indications for or against oophor- 
ectomy have previously been stated, and attention has been called to 
the necessity of studying the pathology in situ, the variety of the 
infection, the points bearing on the individual case, such as the age 
of the patient, her nervous temperament, the desire for maternity, 
the condition of the opposite ovary, the correlation of the circumstances 
attending each individual case, and the study of the after-histories of 
such cases previously operated upon. Even a small series of cases 
carefully studied is of much more value in perfecting the surgical 
judgment than is a large series superficially reviewed. 

The importance of maintaining an adequate blood-supply to the 
ovary can hardly be overestimated. Lack of care in this respect is 
responsible for the majority of failures following this operation. 
Clinical and experimental investigation has repeatedly demonstrated 
that if the blood-supply is seriously impaired, enlargement, due to 
cystic degeneration and edema, and the production of symptoms 
often so severe as to require operation, will result. In the more 
favorable cases the cystic change is followed by atrophy. In con- 
sidering the operation of salpingectomy, it is important to remember 
the results that follow ligation of a blood-vessel. When a vessel ^ 
tied ofT, its lumen, for a varying distance, becomes occluded by 

' Polak, J. 0.: Amer. Jour. Med. Assoc, December 14, 1912, p. 2138. 



tkrombus, which in many cases extends to the main trunk from which 
the vessel originated, with the result that the thrombosed portion 
of the vessel becomes converted into a fibrous cord. Thus it must 
be borne in mind that when ligating an artery in the upper part of the 
broad hgament, the area supplied by the vessel, for some distance to- 
ward the cardiac side of the ligature, is obhterated. It is true that 

Fig, 29. — Diagram of the Blood-supply op the Fallopian Tube. 
This drawing is the result of a large series of injections made for the purpose of ascertaining the tubal blood- 
supply, and although the small vessels varj' somewhat in different specimens, the usual picture is that here 
represented. A group of blood-vessels supplies the ampulla of the tube. These vessels are almost constantly 
present. Another vessel supplies the isthmus. In about 15 per cent, of cases this vessel branches slightly above 
the ovary, forming two trunks before reaching the tube. At the point of the utero-ovarian anastomosis, just 
beneath the cornu of the uterus, one or two vessels are given off, which penetrate the myometrium immediately 
beneath the tube. It is of the utmost importance, when jwrforming a salpingectomy and conservation of the 
ovary, that these vessels be ligated and not the underlying utero-ovarian anastomosis. If, inadvertently, the 
utero-ovarian anastomosis is included in the ligature, disturbance of the ovarian circulation, with subsequent 
cystic change of the ovary, is almost sure to occur. 

the collateral circulation more or less compensates for this deficit. 
But when the blood-supply of the ovary and upper portion of the 
broad ligament is carefully studied, it can easily be seen how ligation 
en masae, such as is often practised during the permforance of sal- 
pingectomy, is certain greatlj' to disturb the circulation of the ovary. 
If the chief vessels comprising the utero-ovarian anastomosis are 
ligated, as they may easily be unless the ligatures are introduced with 


this point in mind, subsequent degeneration of the ovary is sure to 
occur. The utero-ovarian anastomosis is especially likely to be ligated 
at the uterine cornua, where the large vessels approach the tube 
somewhat closely. 

Clark^ has shown that the primordial follicles that normally de- 
velop in the substance of the ovary reach the surface as a result of 
two factors, namely, increase in size and the fact that they are pushed 
to the periphery by the constant pulsation of the ovarian arteries 
behind them. It would seem safe to assume that when the ovarian 
circulation is impaired, the ovarian arteries pulsate with less force, 
so that although the maturing follicle might reach the periphery of 
the ovary, the arteries would not possess sufficient pulsating force to 
produce a necrosis of the tunica albuginea, lying between the follicle 
and the surface, and which, in the normal ovary, occurs just before 
the rupture of the follicle. Under such circumstances the follicle, 
coming in contact with the dense and perhaps thickened tunica al- 
buginea, would fail to rupture and result in a retention cyst. This 
the author believes to be one of the chief reasons why cystic degenera- 
tion follows impairment of the blood-supply in this locality. The peri- 
oophoritis which results in thickening of the capsule of the ovary that 
is often present, and the impairment of the return venous circulation, 
as suggested by Brown,^ which causes edema, are also contributing 

No matter how carefully the ovarian blood-supply is conserved 
at operation, if the ovary is allowed to prolapse, dyspareunia is sure 
to occur, and edema and cystic degeneration, due to deranged blood- 
supply, are likely to follow. If, on the other hand, the mesosalpinx 
is put on the stretch by improper ovarian suspension, the lumen of 
the ovarian vessels is decreased as a result of tension, and a similar 
result takes place. In other words, the correct introduction of liga- 
tures and suspension of the ovary are both essential for the proper 
maintenance of the blood-supply and hence to successful ovarian con- 
servation. If the ovarian circulation cannot be properly conserved, 
oophorectomy should be performed. 

Two other important factors contribute to the ultimate success of 
this type of operation : these are the suspension of the uterus and care- 
ful peritonealization. In cases of pelvic peritonitis the great majority 
of uteri are more or less retrodisplaced. No matter how carefully the 
salpingectomy and ovarian suspension have been performed, if the 
uterus is left in a posterior position, subsequent trouble is likely to 

' Clark, J. G.: Contributions to the Science of Medicine, 1900. 

' Brown, L. R.: Jour. Amer. Med. Assoc, December 14, 1912, p. 2140. 

Fig. 31. — Bilateral Salpingectomy, Ovarian Conservation, and Suspension of the Ovary and Uterus. 
First step; The blood-vessels supplying the ampulla and isthmus of the Fallopian tube have been ligated, 
and the ends of the former ligature left long for a tractor. The tube has been excised as far as its uterine attach- 
ment, and the ligature to control the vessels supplying the intramural portion of the tube has been inserted, 
but not tied. A broad cuff of mesosalpinx has been conserved above the ovary. (The suture to control the 
subtubal vessels should be passed somewhat more deeply into the uterus than shown in the above.) 


occur. These details are repeated here because the author beUeves 
them to be of great importance, and hence will explain the necessity 
for the steps in the following operation in contradistinction to the older 
methods of salpingectomy. 

Operation. — A median incision of sufficient length to allow a free 
exposure should be made. With the patient completely anesthetized 
and in the Trendelenburg position, the intestines are packed back. 
Thorough walling off of the upper peritoneal cavity is an important 
step in all abdominal operations for pelvic inflammatory disease. 
Adhesions are then separated, especial care being taken to free the tube 
throughout its length from adhesions that may bind it to the ovary or 
broad ligament. This is of importance so that as broad a portion of 
the mesosalpinx as possible may be present before excision of the tube is 
begun. A fine catgut suture is then passed through the upper portion 
of the mesosalpinx, about 0.5 or 0.75 cm. below the tube, and about 
1.5 or 2 cm. from the outer edge of the infundibulopelvic ligament. 
This is tied, and the ends are left long for use as a tractor. This 
ligature controls the blood-vessels supplying the distal centimeter or 
two of the tube. The outer end of the tube is then grasped with a 
hemostat, and the tube cut from the mesosalpinx to a point about 0.5 
cm. from its uterine extremity, especial care being taken to incise the 
mesosalpinx through its extreme upper border, so as to leave the blood- 
supply of the ovarj' unimpaired, and a broad cuff of mesosalpinx above 
the ovary for future use in the ovarian suspension. After separating 
the tube from the mesosalpinx one or sometimes two blood-vessels 
are commonly seen spurting in the regions that lie beneath the inner 
portion of the ampulla of the tube and the isthmus. In his injection 
work the author has found one vessel quite constantly in this locality. 
This bleeding is now secured with a fine catgut ligature, care being taken 
to pass the ligature through the upper borders of the cut edge of the 
mesosalpinx, and to tie it in such manner that the latter is not puckered. 
By puckering the free edge of the mesosalpinx the latter is shortened, 
and the underlying blood-vessels are also puckered to a greater or 
lesser extent and the circulation thereby impaired. If the sutures are 
pa.ssed through the mesosalpinx at some distance from its cut edge, 
more blood-vessels than are necessary are ligated, with a .similar 
result. Only sufficient mesosalpinx should be included in this suture 
to secure safe anchorage for the ligature. By separating the tube from 
the inesosali)inx as just descriln'd, before ligating, the individual ves- 
sel or vessels maj' be more easily picked up, fewer sutures are re(|uire(l, 
and puckering is less likely to occur. As an extra precaution against 
infection the tube may at this jxiint \)v \\\-a\)\)M in a piece of sterile 



gauze. A suture should next be passed through the lateral uterine 
wall, immediately beneath the intramural portion of the tube. Especial 
care should be observed to see that this suture embraces only the ex- 
treme upper and inner edge of the mesosalpinx. If the suture is passed 
deeply into the broad ligament, the utero-ovarian anastomosis may be 
ligated. The author's injection work has shown that there is always 
one and sometimes two branches given off from the utero-ovarian 
anastomosis at this point, and that these enter the uterus immediately 
beneath the tube — the subtubal vessels; it is to control these vessels 
that this ligature is employed. The intramural portion of the tube is 
excised with the ordinary wedged-shaped incision, and the uterine wound 
closed with two or three interrupted fine catgut sutures. Richardson's' 
single or double figure-of-8 suture serves admirably for this purpose. 
The round ligament is now picked up at a point 
about 2 or .3 cm. from the uterus, and drawn up 
and plicated, by means of two or three fine Pagen- 
stecher sutures, over the uterine wound. If it is 
deemed advisable, a greater portion of the round 
ligament may be utilized — enough to bring the 
uterus forward in good position. This procedure 
shortens the round ligament, elevates it in the 
pelvis, suspends the uterus, and covers in the 
uterine salpingectomy wound and the inner two- 
thirds or three-fourths of the raw edge of the 
mesosalpinx. The extreme upper edge of the 
cuff of mesosalpinx above the ovary is then 
sutured to the round ligament by means of two or three catgut sutures, 
the same care being observed in passing these sutures . through the 
mesosalpinx as was taken in ligating the blood-vessels. Except that 
the ovary is drawn forward 1 or 2 cm., its normal position is retained, the 
organ hanging naturally on the posterior surface of the broad ligament. 
Even an enlarged and heavy ovary can be well suspended in this man- 
ner. If, however, the ovary to be conserved is the seat of one or two 
large retention cysts, it is a better plan to puncture these and thus re- 
duce the weight of the organ. The operation may cease at this point, 
as practically all the requirements have been fulfilled. If the peri- 
toneum is not too adherent, the author prefers to utilize this structure 
also for the uterine suspension. Coffey- has shown its great value 
in this connection. The peritoneum on the anterior surface of the 
broad ligament, at a point about 3 cm. below and 1 cm. outside of the 

' Richardson, Edward H.: Jour. Amer. Med. Assoc, May 7, 1910, vol. liv, p. 500. 
= Coffey, Robert C: Surg., Gyn., and Obst., October, 1910. 

Fig. 32.— Rich-\rdson's Sin- 
gle (a) AND Double (b) 
FionRE-OF^S Suture 
(Richardson, E. H.: .Jour. 
Amer. Med. Assocs May 
7, 1910). 


I'l';. ;i3. — BiLATKHAi. SvLi-iNGECTOMv, Ovarian Conservation, AND SusPExsinN -t im > , - : >. . i ii , . - 
Second atep: Hemostasis has been secured, as shown in the previous illustration, and the wounds left from 
the excision of the intramural portion of the tubes have been closed by two or three interrupted sutures of fine 
catgut or by Richardson's figure-of-8 stitch. The round ligaments have been plicated over the uterine wound 
by two or three Pagenstecher threads, sufficient of the ligaments being utihzed to effect a suspension of 
the uterus. On the patient's right side of the ovaiian suspension sutures are in place, but not tied, while on 
the left side the ovary has been suspended. If the peritoneum of tho anterior layer of the broad ligament is 
unusually adhert-nf. the operation may cease at this point. 

Fio. ."M. — DtLATBnAL SALPiNnKtrroMV, Ovarian Conservation, and Suspension of the Ovary and TTEKrH. 
Third Htep: It in of advantage, when possible, to utilize the peritoneum of the anterior layer of the broad 
I Muspension medium. For thih" purpose a point somewhat below and ulightly outside of the uterine 

iired to the uterus 
illimtnition. The 
id ligament irt not 

lianment 1) 

insertion of the roun<l liganient is selected, and the peritoneum from here lifted up am 
over the plieated portion of the round ligamenl by a fine eatgul suture, as shown in 
Cuihing Htiteh is a Roml one for this purpose. If the stump at the outer end of the 

mI by this procedure, entire peritonealization may be accompliMhe<l by a fine catgut sutur 


origin of the round ligament, is lifted up and tacked over the pHcated 
round Hgament on the uterine cornua, so as to envelop the latter. 
This entirely covers all raw areas and adds materially to the strength 
of the uterine suspension. If the appendages of the opposite side are 
normal, the ordinary Coffey uterine suspension operation may be per- 
formed on that side. In cases in which it is necessary to perform a 
salpingo-oophorectomy the same method of plication of the round liga- 
ment and peritonealization may be employed. 

The salpingectomy, as previouslj' described, although somewhat 
more tedious than the ordinary operation, has been productive of so 
much better results, so far as the ultimate ovarian conservation is 
concerned, that the author has practically al^andoned all other methods 
in its favor. In one case in which an opportunity arose to examine the 
suspended ovarj' nearly one year after the suspension, the organ was 
found to be in excellent condition. In three other cases in which 
unilateral salpingectomy has been performed pregnancy has fol- 
lowed and the subsequent labors have been normal, and the uteri 
have retained their normal positions. An endeavor has been made 
to keep track of all cases, and a large number have been examined 
binianually from time to time. In all those operated upon by this 
method good results have been obtained so far as ovarian conservation 
is concerned, and in no case, as far as has been learned, have degenera- 
tive changes taken place in the retained ovary, nor have any of these 
ovaries given rise to subjective symptoms. The proportion of cases 
in which normal menstruation has been retained after a salpingo- 
oophorcctom}' on one side, and a suspension of the ovary by the fore- 
going means on the ojiposite side, is distinctly l)etter tlian when other 
methods have been employed. 

Before adopting the method just described, a number of operations 
for ovarian suspension have been tested in the Gynecologic Depart- 
ment of the University Hospital. At first the ovary was let alone 
after excision of the tube, and then an endeavor was made to suspend 
the ovary fioin the round ligament without plicating the latter. 
Neither of these operations was entirely satisfactory, and for a time the 
ovary was suspended from the cornua of the uterus. If mass sutures 
are employeil in tying off the mesosalpinx, this structure l)ecomes nnich 
puckered, and a false sense of ease is (>ncf)untereil in bringing the ovary 
to the uterine cornua. Such a procedure interferes materially with tiie 
ovarian circulation, and in a large jiroportion of cases degeneration of 
tlic ()\ary results. 

Partial Oophorectomy. In sonic cases resection of an o\'ary offers 
fiiv()ral)Ic results. The presence of pus in the ovary is usuall,\' an iiidi- 


cation for its removal. Esch^ regards the pus contained in ovarian 
abscesses as peculiarly virulent. Many such cases are undoubtedly 
of puerperal origin, the pyogenic microorganisms having traveled di- 
rectly through the broad ligament to the ovary. Notwithstanding 
this, in carefully selected cases resection may be performed with fairly 
good results. If it is found necessary to remove the opposite ovary, 
or if the abscess is a small one and is so situated that it may easily 
be excised, and even if only a small amount of ovarian tissue can be 
left behind, the sudden onset of the menopause is generally averted. 

Stokes- has had three cases of pregnancy following complete 
removal of one ovary and at the same time the major portion of the 
opposite one, showing definitely that in suitable cases, and when the 
operation is properly performed, these ovaries functionate in a normal 
manner. Humiston^ reports 112 cases with no mortality. The after- 
histories of 70 of these cases have been followed : 19 of the number have 
given birth to 21 children, and 3 have returned for a second operation. 
None of the cases included in this list have been operated upon less 
than three years ago. The condition of the opposite ovary is not 

Watkins^ states that he resects small abscesses in the ovaries in 
young women, preferring to run the risk of secondary trouble to pro- 
ducing an early menopause. As yet he has had no unfavorable results. 

In general it may be stated that resection of an ovary possesses a 
limited field of usefulness in gonorrheal conditions, the proportion of 
those cases that' require a secondary operation being much higher than 
where an entire ovary is conserved. This is due to two factors: in 
the first place, resected ovaries are always diseased organs, and in 
the second place, apart from the mutilation necessary, the circulation 
is often interfered with by the ovarian sutures. These are necessarily 
passed deeply into the substance of the ovary, and as this organ is sup- 
plied by a central circulation, the latter is always more or less dis- 
turbed. Furthermore, the follicle-bearing portion of the ovary is 
usually the part diseased, and therefore the most important portion 
of the ovary is likely to be removed by resection. Polak,^ in his pains- 
taking study of the after-histories of these cases, remarks that all 
resected ovaries become much enlarged after the operation. In the 
favorable cases this enlargement begins to subside in about four weeks. 

' Esch: Zeitschr. f. Geb. u. Gyn., 1907, vol. lix, No. 1. 

- Stokes, J. E.: Old Dominion Jour. Med. and Surg., Richmond, 1911, vol. xii, p. 2.iri. 

^ Humiston, W. H.: Amer. Jour. Obst., January, 1913, p. 120. 

* Watkins, T. J.: Jour. Amer. Med. Assoc, December 14, 1912, p. 2140. 

' Polak, J. O. : Jour. Amer. Med. Assoc, October 23, 1909, p. 1382. 


Turretta^ has studied the after-results in a large series of ovarian re- 
sections, and speaks favorably of the operation in selected cases; 
he believes that the reparative power of the ovary is very great. 
Zacharias- has traced the after-histories of three cases, in each of which 
one ovary was removed and the other resected. In none of these 
patients did any untoward symptoms arise, and all were menstruating 
regularly several years after the operation. Pugnat' believes firmly 
in the regenerative power of the ovary, and declares that new germinal 
epithelium is produced, together with the formation of new primordial 
and Graafian follicles. This latter statement, while interesting, 
must be confirmed bj' further observation before it can be accepted. 
Di Christina^ believes that the cut surfaces of a resected ovary heal 
by connective-tissue production, and that the cicatrix is generally 
pushed to the surface. The author had the opportunity of examining 
histologically two ovaries upon which resection had been performed. 
Serial sections were made of these organs, and no confirmatorj' evi- 
dence was obtained that new ovarian tissue was produced to take the 
place of the resected portion. Both specimens were of nearly normal 
size. In one the scar could be distinguished macroscopically, whereas 
in the other it could be detected only microscopically as a thin line 
of avascular connective tissue on the surface. That compensatory 
hj'pertrophy — a verj^ different process from regeneration — does take 
place seems to be certain. This belief is borne out b\' the study of 
clinical material and bj' the work of Carmichael and Marshall,^ which 
has been discussed elsewhere. 

The most favorable cases for resection are those in which a single 
retention cyst is present, and this is especially true when the cyst tends 
to become pedunculated. These single retention cysts should not be 
confused with cystic degeneration of the ovaries. The latter condi- 
tion offers very poor results from any form of conservative surgery. 
Boldt,^ in performing oophorocystectomy, endeavors to save a portion 
of the ovary, and in 45 cases had only one bad result. The necessity 
for leaving the ovary with an unimpaired blood-supply cannot be over- 
estimated, and if this is found to be impossible, ooi)horectomy should 
be performotl. 

It has been stated that ovaries that are allowed to remain after 
removal of the uterus or of the corresponding tube give rise to subse- 

' Tiiru'tta, S.: II Policlinico, January 3, 1909. 
' Zaohuriii-s, P.: Zeit. f. Gyn., Leipzig, January 25, 1908. 
' I'unnat: Quoted Ijy Di Christina: Monats. f. Geb. u. Gyn., vol. xxii, No. 5. 
•' Di Christina: Monat.s. f. C!ol). u. Gyn., vol. xxii, No. ii. 

' Carmichael, E. S., and Marshall, F. A. V.: Brit. Med. Jour., 1907, vol. ii, p. I.'j72. 
' Ho!(lt, H. J.: Trans. Amer. Gyn. Soc., Philadelphia, 1909, vol. xxxiv, p. .327. 


quent trouble, often undergoing polycystic degeneration and becoming 
enlarged and tender, and sometimes prolapsing into Douglas' culdesac ; 
or if this does not occur, that they become adherent and painful. 
Unfortunately, there is no doubt that this is sometimes the case. 
The author is, however, of the opinion that in these cases the fault lies 
not so much in the ovary, as in the method of performing the sal- 

The important factors to be considered in conservative ovarian 
surgery are the maintenance of a proper blood-supply and the securing 
of the ovary in good position, preferably in its normal location in the 
fossa obturatoria (Waldeyer). If these two points are observed, 
cystic degeneration of the ovary, dyspareunia, and other distressing 
symptoms can be averted. Furthermore, this opinion is strengthened 
by the review of the after-histories of engrafted ovaries, which almost 
invariably become cystic. Souve,^ in his exhaustive study of ovarian 
transplantation, finds that cystic degeneration almost uniformly 
supervenes. This, he believes, is due to an imperfect blood-supply. 
A similar conclusion is reached by Kawasoye,^ Mcllroy,^ and others. 
Special attention should be directed to covering all raw areas, so that 
adjacent organs may not become adherent, and, by the formation of 
post-operative adhesions, cause as much discomfort as the original 
condition. All rough handling and trauma of the ovary during the 
operation should be avoided. In those cases in which a resection has 
been performed, especial care should be taken accurately to coaptate 
the cut surfaces' of the ovary, but not to constrict the tissue in doing so. 
Fine catgut sutures should be passed in such a way that no dead space 
will remain. Absolute asepsis and hemostasis should be secured. 
Martin'' very properly strongly emphasizes the necessity of checking 
all bleeding points in cases of pelvic inflammatory disease. No better 
culture-media exist than blood-clots. A fine needle and fine catgut 
are requisites to successful conservative ovarian surgery. 

In conserving ovaries, as in all other forms of surgery, the ability 
to make the diagnosis while the affected organ is in situ is of the utmost 
importance, and for this reason surgeons should accustom themselves 
to study removed tissue with great care. 

It is quite as important that the uterus, as well as the ovary, be 
left in good position. If no attention is paid to this detail, the uterus 
may, by exerting traction on the broad ligament, set up a disturbance 

' Souve: Bull, de la vSoo. Anat. de Paris, November, 1907. 
' Kawasoyp, M.: Zeit. f. Geb. u. Gyn., 1912, vol. Ixxi, No.s. 1 and 2. 
^ Mcllroy, A. L.: Jour. Obst. and Gyn. of Brit. Emp., July, 1912, p. 19. 
* Martin, F. H.: Sur^.. Gyn., and Obst., April, 1907, p. .501. 


in the ovarian circulation or actually drag the ovary into a painful 

Ovarian Conservation After Hysterectomy 
Cases in whicii ovarian conservatism is possible when hysterectomy 
for pelvic inflammatory disease is demanded are rare, the general rule 
being that when it is necessary to remove the uterus, both ova- 
ries are so diseased as to require their ablation. Indeed, bilateral 
oophorectomy is usually the indication for the hysterectom^^ Never- 
theless, occasionally cases may be encountered, and when such is the 
case, the ovary or ovaries should be left behind. Conservative ovarian 
surgery after hystero-myomectomy has amply demonstrated the 
physiologic success of this procedure, as exemplified by the work of 
Polak,' Holzback,'- Dickinson,^ Kelly and Cullen,* Konstantinides,^ 
Clark and Xorris,'^ and many others. Polak' states that the nervous 
phenomena are more marked when the patient operated upon is in good 
health, and that the post -operative menopause occurs less often after 
total extirpation for pelvic inflammations than when the ablation is 
performed for fibromyomata. Dickinson* observes that conservation 
of ovarian structure after hysterectomy showed 80 per cent, of the 
patients to be free from disturbances of the surgical menopause. In 
married women the conservatism showed nearly uniform persistence 
of the sexual desire. Dickinson' strongly opposes the practice of re- 
moving normal ovaries when performing a hysterectomy at or near the 
menopause, on account of age. In cases of pelvic inflammations ova- 
rian conservation should be governed bj^ the same rules as previously 
suggested. The maintenance of the proper blood-supply is of the 
utmost importance, and unless this can be obtained and the ovary 
left in a position secure from prolapse, its removal is indicated. The 
author's custom has, in this respect, been similar to the operative pro- 
cedures recommended by Polak,'" who raises the ovary well up and 
suspends it from the round ligament, especial care being observed to 
avoid inflicting trauma on the ovary and to cover all raw areas. In 
7 cases previously rccortled" no ill effects have occurred, and the un- 
pleasant phenomena of the surgical menopause have been absent. 

' I'oliik: Surn., (lyn , :in(l Obsl.. .Inly, 1111 1. 

= II()lzl)ack: Arrli. f. (!yn.. vol. Ixxx, No. •_', 

' Dickinson: .Surg.. (;yn., ami Ohsl,, .July, lidl. p. W'.l 

' Kelly und CuUen: Myoniata of the I'teriis, edition, l'.)()0. 

' Konstantinide.**, (1.: Miinch. mod. Woehensehr., H»10, No. 9, p. 491. 

• Clark, J. G., and Norris, C. C: Surg., Cyn,, and, October, l<.)in. 

' Polak: Suri;.. Cyn., and Okst., .July, 1911. 

'Diekin.son: SurR., (!yn., and Olist., .July, 1911, p. 99. 

» Dickin.son: Lor. Hi. "' I'olak: .'^urn., 'lyn., and (»li-.i,, .July. I'.Ml. 

" Clark, J. U., and .Norris, C. C: SuriJ.. Cyn., and Oh.^l., ()(t,.l,(M-, 1910. 


With our inoreased knowledge of the function of the ovaries, and 
with the cognizance that without these adjuncts the uterus is a useless 
organ, and that a better support to the roof of the vagina may be ob- 
tained by a supravaginal hysterectomy, most operators are agreed as 
to the advisability of performing a hysterectomy whenever a double 
oophorectomy is required. Reed' has recently pointed out that such 
uteri, if allowed to remain behind, are frequently the cause of much 
suffering. Giles^ found that in 62 cases in which a bilateral salpingo- 
oophorectomy was performed the uterus subsequently gave trouble 
in 7, and 2 required a second operation. This observer presents the 
following table, showing the atrophic results following bilateral 
salpingo-oophorectomy : 

Under Under Over Total 

Two Years Five Years Five Years Number 
Per Cent. Per Cent. Per Cent. of Cases 

Utenis and vagina normal 38 26.7 18 17 

Uterus or vagina atropliied 31 33.0 54 20 

Uterus and vagina atrophied 31 40.0 27 18 

Total 5o 

This is another argument in favor of removal of the uterus when it is 
found necessary to perform a double oophorectomy. 

Kerr^ also emphasizes the importance of removing the uterus when 
a bilateral salpingo-oophorectomy is necessary. Carmichael and Mar- 
shall^ found that in young animals, when the ovaries were removed, 
the uterus underwent fibrous degeneration. 

Curetage. — A thorough curetage and iodinization of the uterine 
cavity should precede all abdominal operations for pelvic inflamma- 
tory disease. If a supravaginal hysterectomy is to be performed, this 
procedure lessens the danger of infection when the cervix is cut across. 
When the uterus is to be spared, curetage and the application of iodin 
not only increase the hkelihood of a complete cure, but also lessen the 
dangers of infection from a uterus often the seat of a chronic endo- 
metritis, to the adnexa, which are not to be removed at operation. 
Stone'' not only employs iodin routinely in the uterine cavity, but also 
irrigates the Fallopian tube through the abdominal incision when the 
oviduct is to be saved. He states that no unusual reaction follows 
irrigation of the tubes with a solution composed of 25 or 50 per cent. 

' Reed: New York Med. Jour., March 5, 1910. 

=.Giles, A. E.: Jour. Obst. and Gyn. of Brit. Emp., March and .\pril, 1910. 

« Kerr, J. M. M.: Jour. Obst. and Gyn. of Brit. Emp., 1910, vol. xvii, p. 4.58. 

< Carmichael, E. S., and Marshall, F. A. F.: Brit. Med. Jour., 1907. vol. ii, p. 1.572. 

'Stone: The Virginia Medical Semi-Monthly, June 7, 1912, p. 105. 



of the tincture of iodin, but that there is, rather, diminished pain. 
Bovee' is a strong advocate of the employment of iodin in the uterine 
cavity prior to abdominal section. 

The CoNDrxioN of the Vermiform Appendix in Cases of Pelvic Perxtgnitis 
The exact relationship existing between the vermiform appendix 
and the right uterine adnexa is difficult to determine accurately. The 
clinical fact that the appendix is frequently secondarily involved in 
cases of pelvic inflammatory disease is well known. The converse 
occasionally takes place, as observed by Watkins.- As regards the 
appendiculo-ovarian or dado's Ugament, little doubt remains as to 
the existence of this structure. It is, however, in the author's ex- 
perience, far from constant, and indeed the cases in wliich it can posi- 
tively be demonstrated constitute the minority. When it is present, 
it appears merely as a redupUcation or thin fold in the loose peritoneum 
of the right iliac fossa. Deaver and Testu,^ Treub, Dutilh, Olshausen, 
Kronig, and Diiderlein'' refer to Clado's ligament as a distinct ana- 
tomic entity, and believe that this structure can be regarded as a 
causative factor in the production of tubal disease compU eating ap- 
pendicitis. Kelly and Hurdon^ and Hartmann,^ while admitting the 
occasional presence of a thin fold of peritoneum which connects the 
cecum or meso-appendix with the infundibulopelvic ligament, posi- 
tively deny that this structure is ever a vascular or a lymph com- 
munication between the ovary and the vermiform appendix, and this 
is the attitude taken by the majority of the present-day anatomists. 
Hyde^ explains the frequent inflammatory lesions of the vermiform 
appendix found in connection with pelvic inflammatory disease on the 
ground of gravity, and believes that this plays an important part in 
producing such conditions. Increased peristalsis, the different bodily 
po.stures, a loaded cecum, a dislocated appendix, enteroptosis, and a 
long appendix with a correspondingly long meso-appendix, combined 
with gravity, Hyde* concludes, simply bring the appendix and adnexum 
into juxtaposition, whereas inflammatory lesions, present in either, 
with the localized peritonitis, arc responsible for the adhesion of the 
one to the other. 

Of late years many operators have made a practice of perfcjrming 

' l5ovi5c, J. W.: .Vincr. Jour. Med. .\s,soc., July 27, 1912, p. 2.'>2. 
- Watkins: .\mer. Jour. Obst., 1909, vol. lix, p. 03.5. 

' Dcavor and Testu; Quoted by Hyde, C. R.: Ainer. Jour. Obst., June, 1911, p. 1059. 
' Trciil), Oiiiilh, Olshausen, Kronig, and Doderlcin: Quoted by Jones, H. M.: Lancet, 
July 29, 1911, p. 29.-). 

' Kelly an<l Hurdoii: The Vermiform .Vppendi.x and its Di.scases. 

• Ilartmann: (Quoted by Jones, H. M.: Lanoet, July 29, 1911, p. 295. 

' Hyde, C". H.: Anier. Jour. Obst., June, 1911, p. 10.59. • Hyde, C. R.: Loc. cil. 


an appendectomy in nearly all cases in which the abdomen is opened, 
regardless of the history of the case and the macroscopic appearance 
of the appendix. Von Rosthorn' has pointed out the fact that there 
is no other class of cases in which the appendix is so likely to be dis- 
eased as in pelvic peritonitis. Pankow- has examined 150 vermi- 
form appendices from Kronig's clinic, which were removed in the 
course of gjaiecologic operations, and has found 1 13 diseased. Hermes, 
in 75 cases, found the appendix diseased in 53, and noted this condi- 
tion more commonly in multiparse than in primiparse. Robb,^ under 
similar conditions, removed 218 appendices and found 209 diseased. 
Legueu* states that of 17 appendices removed during the course of 
a right-sided or a double salpingectomy for salpingitis, 16 presented 
definite lesions, 15 of these being a peritoneal or subperitoneal inflam- 
mation, acute in character, and evidently occurring by way of the 

In the University Laboratory of Gynecologic Pathology there are 
327 appendices that were removed coincidentally with operations for 
pelvic peritonitis; of these, macroscopic examinations showed 207 
diseased, whereas histologic examination showed 246 inflamed. The 
entire series presents the following results: Normal appendices, 81; 
peri-appendicitis, 100; chronic appendicitis (various forms). 111; con- 
cretion in appendix, 33; primary carcinoma of the appendix, 3. In 
quite a definite proportion of these appendices disease could not be de- 
tected macroscopically, whereas in none of the cases of cancer was the 
nature of the condition suspected until the organs reached the labora- 
tory. The author believes that in all conservative or radical operations 
for pelvic inflammatory disease appendectomy should be performed 
unless there are unusual operative difficulties or the patient's general 
condition is such that a few minutes' adtlitional anesthesia would be 
hazardous. Even normal appendices, if not remo^'ed, will frequently 
cause subsequent trouble. In the Gynecologic Department of the 
University Hospital we have been forced to operate on not a few cases 
in which the appendix had not been removed at a pre\-ious operation, 
and had subseciuently become adherent or inflamed. 

That the radical operations carry with them a higher mortaUty 
than the conservative operations cannot be doubted. The following 

' Von Rosthoin, A. : Monats. f. Geb. u. Gyn., September, 1909, vol. xxx, No. 3. 
- Pankow: Beitrage zur Geb. u. Gyn., vol. xiii. No. 1. 
' Robb, H.: Trans. Amer. Gyn. Soc, Philadelphia, 1906, vol. xxxi, p. .331. 
^Legueu: La Gyndoologie, 1911, vol. xv, p. 14.5. 




results, gathered from statistics from various sources, bear out this 
statement : 


Conservative Deaths Percentage 
Operations of Deaths 

Manton' 100 0.0 

Robins= 20 0.0 

Simpson' 475 4 0.8 

Giles^ 132 4 3.0 

Dudley^ • 858 9 I.O 

Brothers^ 160 2 1.2 

Browiv 10 0.0 

Jewett, H.« 32 2 6.2 

Gynecologic Clinic, University Hospital' 321 7 2.1 

Total 2108 28 1.3 

An analysis of our statistics shows that of the 7 deaths, 2 died of 
pneumonia and that 2 were nearly moribund at the time of operation, 
one dying on the table and the other within a few hours, both having had 
general peritonitis before the operation. One case died of obstruction; 
one of intestinal atony, and one of general post-operative peritonitis. 

Martin'" presents the following statistics from the Birmingham 
Hospital for Women : 

Unilateral oophorectomy 

Bilateral oophorectomy 

Unilateral salpiiiKeetomy 

Bilateral salpingectomy 

Vapinal incision 

VarioiLs eonser\'ative operations on the appendages, 
such a-s ovarian resection, relief of adhesions, etc. . . . 






Tlic chief object to he attained in all forms of surgery is to cure the 
patient with as little as possible. The possibility of relieving the 
immediate troul)le, but in doing so superimposing a worse condition 

' Manton, W. P.: Trans. Amer. Gyn. Soc, Philadelphia, lOOd. vol. xxxi, p. l'J7. 
- l{ol)ins, ('. K.: Old Dominion Jour. Med. and Surg., Richmond, lilOS, vol. vii, p. 18"). 
' Simpson: Jour. .Vmer. Med. Assoc., 1909, No. 15, vol. liii, p. 1175. 
' Gilex, A. K.: Jour. Obst. and Gyn. of Brit. Emp., March and April, I'.tld. 
'• Dudley, A. P.: Jour. .\mer. Med. Assoc, vol. xli. No. 24, p. 1446. 
" Brothers, A.: Jour, .\nier. Med. .\ssoc., February 22, 190S, p. 505. 
' Brown, G. V^ A.: Jour. Michigan Med. .\.ssoc., Detroit, .Scptcuiljcr, I'JU.S, vol. vii, 
p. 44!l. 

» Jewett, H. : Jour. Obst. and Gyn. of Brit. Emp., 1907, p. 312. 

•Clark, J. G., and Norris, C C: Surg., Gyn., and Obst., October, 1910. 

"> Martin, C.: Brit. Med. Jour., October 26, 1912, p. 1110. 


than that from which the patient originally suffered, has previously 
been dwelt upon. Although the results may be good at the time of 
discharge from the hospital, it by no means follows that the patient 
will henceforward suffer no ill effects from the operation or have no 
recurrence of the original disease. The latter, possibly, is particularly 
likely to occur in conservative operations for pelvic inflammatory 
disease. The following are some of the end-results obtained in this 
class of cases by other operators. 

Giles' cured 120 of 132 cases. 

Polak- cured 106 of 300 cases. 

Robins' had 20 cases and cured 20 cases. 

In our series of 191 cases, 140 were cured, 40 improved, and 11 
showed no improvement. In these cases only such patients were 
classed as cured as evinced no symptoms. No cases are included that 
were operated on during the past year, an important point in compiling 
statistics such as these, for by including recent cases recurrences cannot 
be known. The fact that removal of one ovary has a tendency toward 
diminishing the amount and duration of menstruation and establishing 
a somewhat earlier menopause than in the case of a patient possessing 
both these organs has previously been dwelt upon. In a certain pro- 
portion of cases, however, in which a unilateral oophorectomy is per- 
formed, menorrhagia or metrorrhagia results. Brothers^ reports this 
condition in 14 of his 66 cases. The symptom is usually transitory, 
and is probably due to disturbance of the vasomotor centers and of the 
entire genital tract, the cycle of which centers about the ovaries. 
In our series irregular, profuse menstruation was present for a short 
time in 97 cases, but after one year only 9 cases suffered from this con- 
dition, whereas 10 additional patients complained of irregularities 
without mentioning the character of the flow. 

In this connection the work of Vertes^ is especially interesting. 
This investigator reports the results of his observations in a series of 
67 cases in which one or both ovaries were removed, the uterus being 
allowed to remain. In none of the cases was vaginal drainage em- 
ployed, nor were any cases of extra-uterine pregnancy included, so 
that in no instance would extraneous features be called into play. 
Vertes' conclusions are as follows: If the interval between the last 
menstrual period and a unilateral oophorectomy is longer than twelve 
or thirteen days, then bleeding which subsequently appears may be 

' Giles, A. E.: Jour. Obst. and Gyn. of Brit. Emp., March and April, 1910. 

2 Polak, J. O,: Jour. Amer. Med. Assoc, October 23, 1909, p. 1382. 

' Robins, C. R.: Old Dominion Jour. Med. and Surg., Richmond, 1908, vol. vii, p. 185. 

* Brothers, A.: Jour. Amer. Med. Assoc., February 22, 1908, p. 595. 

5 Vertes, O.: Gyn. Rund., 1912, vol. vi, Nos. 8 and 9. 


regarded as a predisposition to a menstrual flow, and usually proceeds 
with the loss of a less amount of blood than during a normal menstrual 
period. If the interval between the last menstruation and the opera- 
tion is less than twelve days, then the post-operative menstrual flow 
will be subject to delay. This circumstance may be explained by the 
fact that the function of the extirpated ovary must be taken up by 
the organ on the other side, but delay becomes progressively lessened 
until the remaining, ovary has completely adjusted itself to the in- 
creased function. If the ovary which contains a maturing Graafian 
follicle has been left behind at the time of operation, the first post- 
operative period will appear at the normal time, and the delayed flow 
will manifest itself only in subsequent periods. After a bilateral 
oophorectomy a normal menstrual period may appear subsequently to 
the operation if the interval between the last period and the operation 
does not exceed thirteen or fourteen days. 

One of the greatest advantages of conservative operations over 
hysterectomy is the possibihty offered these patients of subsequently 
becoming pregnant; even in patients who do not conceive, the possi- 
bility of childbirth is never positively withdrawn from them. The 
fact, however, that many of these cases do conceive is well known. 
Giles' found that of his patients who were married and under forty 
years of age at the time of operation, 25 per cent, became pregnant 
and went to term. The 19 women who had full-term pregnancies 
bore 25 children, and 5 other patients had miscarriages, while of 
our own 68 cases which were married and under forty years of age at 
the time of operation, and in which sterilization was not performed 
(bilateral salpingectomy), 17 patients have become pregnant and 
gone to term, and were delivered of living children. Three of these 
17 patients have had two children each, while one has borne three. 
In none of the labors was anything more required than low forceps. 
In the series of 68 cases in which pregnancy was possible, in adtlition 
to the 22 children born there were 7 miscarriages, 3 of those occurring 
among the 1 7 women who had borne children. A peculiar case of preg- 
nancy, not included in the for(>going group, occurred among our cases, 
and demonstrated the tendency of the Fallf)pian tube to become 
fiatcnt if it is simply tied off without excising the intramural jiortion. 
This patient was operated upon for double i)us-tubes of unusual size. 
Both ovaries were den.sely adherent and one was much enlarged, due 
to the presence of a retention cyst. Both tubes and the cystic o\ary 

' Giles, A. ]•:.: Jour. Ob.Kt, ami (Ivii. of Urit. Kmp., March and April, 1!)10. 


were removed. The patient took the anesthetic badly, and in order to 
save time the tube was tied off in the old-fashioned way on the side 
upon which the salpingo-oophorectomy was performed. Convalescence 
was uninterrupted. Menstruation was regular, but rather scanty. 
Two years after the operation the patient became pregnant, and sub- 
sequently gave birth to a full-term, healthy child. 

Numerous statistics relating to pregnancy following conservative 
pelvic surgery are on record, but most of these are misleading, because 
important details, such as the proportion of married patients, the 
age of the women, the amount of time that elapsed between operation 
and the compiling of the statistics, etc., are lacking. 

Number of Cases Subsequent Per 

Reported Pregnancies Cent. 

Polak' 240 26 10.0 

Butler 50 1 2.0 

Hyde= 21 1 .3.8 

Manton= 41 6 14.0 

Robb, H 419 0.0 

Baldwin, L. G.-' (quoted by Hyde) 99 0.0 

Dickinson .50 0.0 

Jewett* 67 0.0 

Brothers^ 100 0.0 

Brown, G. V. A.' 10 1 10.0 

Dudley,* after carefully reviewing the after-histories of 2168 cases, 
came to the conclusion that at least 10 per cent, become pregnant, 
whereas Hyde,'-' in summing up a large series of his own and of other 
operators' cases, believes that not more than 5 per cent, become 
pregnant. This latter proportion should probably be at least doubled 
if we take into consideration the age and condition of the patients from 
whom these statistics are computed, for it is obviously incorrect to 
include cases of women past forty or spinsters in these figures. It is 
interesting to note that in Polak's'" series of cases, all of which were at 
the child-bearing age, 17 of the 26 pregnancies followed the ablation 
of the ovary on one side and the resection of the opposite organ. 

1 Polak, .1. O.: Jour. Amer. Med. Assoc, October 23, 1909, p. 1392. 

2 Hyde, C. R.: Amer. Jour. Obst., August, 1907, vol. Ivi, No. 2, p. 14.5. 

' Manton, W. P.: Trans. Amer. Gyn. Soc, Philadelphia, 1906, vol. .\.\xi, p. 197. 

* Baldwin, L. G.: Amer. Jour. Obst., 1907, vol. Iv, p. 203. 

» Jewett, H.: Jour. Obst. and Gyn. of Brit. Emp., 1907, p. 312. 
' Brothers, A.: Jour. Amor. Med. A.ssoc., February 22, 1908, p. .595. 
~ Brown, G. V. A.: Jour. Michigan Med. A.ssoc, Detroit, September, 190S, vol. vii, 
p. 449. 

* Dudley, A. P.: Jour. .\mer. Med. Assoc, vol. xli, No. 24, p. 1446. 

5 Hyde, C. R.; Amer. Jour. Obst., August, 1907, vol. Ivi, No. 2, p. 145. 
'" Polak, J. O.: Jour. Amer. Med. Assoc, October 23, 1909, p. 1382. 



Giles' was one of the first writers to draw attention to the likeUhood 
of ectopic gestation occurring subsequently to a conservative opera- 
tion of the uterine adnexa. Of his patients, 7 subsequently became 
pregnant ectopically, whereas Polak- reports one cornual pregnancy 
following a radical salpingectomy. In our series of 68 cases 2 women 
were subsequently operated on for tubal pregnancy. These figures 
bear out the theory that the chief etiologic factor in the production 
of tubal pregnancy is pelvic peritonitis. If tubal pregnancy is partic- 
ularly prone to follow conservative operations, — and these figures 
indicate that it is, — this factor must be taken into consideration in all 
conservative operations on married women of child-bearing age. 


The fact that a very definite proportion of pelvic inflammatory 
cases subjected to conservative operation require a second operation 
for the recurrence of an old disease, or the further progress of the in- 
flammation into organs hitherto unaffected, is the strongest argument 
in favor of the radical operation. The frequency with which the gono- 
coccus is found as the infective agent in these cases, and also its per- 
sistence, together with the advantages to be derived from delayed 
operation, have previously been dwelt upon; but, nevertheless, even 
with the most careful proliminary treatment and the most prudent 
selection of cases a certain percentage of patients will require a second- 
ary operation, as may be seen from the following table: 

Cases with 

NcMBER OF Cases Secondary 

Reported Operations 

Polak= 300 41 

Baldwin' 99 1 

.Icwett' 67 6 

Oirkinson 50 4 

.ludd 50 2 

.Manton' 100 3 

( !ilfs« 52 4 

Hobl)' 419 10 

Krotlicrs* 85 

( raKin. E. B 33 1 

( "lark and Norris' 190 7 

' Giles, A. K.: .lour. and (iyn. of Brit. ICmp., March and .\pril, 1010. 
' I'olak, J, <).: .lour. Amor. Med.*oc., October 23, 1909, p. 1382. 
' Baldwin, L. G.: Amor. Jour. Obst., 1907, vol. Iv, p. 203. 
« Jcwctt: Jour. Obst. and fJyn. of Brit. Emp., 1907, p. 312. 
» Mnnton, W. P.: Trans. Amcr. (iyn. Soc, Philadelphia, 1900, vol. xxxi, p. 197. 
•Giles, A. E.: Jour. Obst. and Gyn. of Brit. Emp., March and April, 1910. 
' Uobb, H.: Amer. Jour. Obst., 1907, vol. Iv. Thirteen other, however, were ini- 
dcr observation for symptoms, 10 of which were subsequently cured without operation. 
' Brothers, A.: Jour. Amer. Med. A.s.soc., February 22, 19()H, p. .59.'). 
•Clark, J. G., and Norris, C. C: Sui>?., Gyn., and, October, 1910. 


Diihrssen/ from an experience of 1000 cases, believes that not more 
than 2 per cent, require a second operation. 

Thus we find that out of a total of 1445 cases of various operators, 
85, or 5.8 per cent., require a secondary operation, and this is not taking 
into consideration the fact that many of these cases were not subjected 
to preUminary treatment prior to operation. The proportion of cases 
in which an apparently normal tube becomes diseased subsequent to 
the removal of the appendages of the opposite side is difficult to esti- 
mate, owing to the fact that the majority of the statistics on this sub- 
ject are based upon such broad grounds. Giles,^ however, has care- 
fully followed the after-results of 44 such cases, and found that in but 
one did trouble arise. Of our 73 cases in which operations were per- 
formed on one side, the opposite tube being left undisturbed, a second- 
ary operation was required 5 times. In 3 of the 5 cases in which a 
secondary operation was necessary the case histories show that both 
tubes were adherent at the time of operation, whereas in the other 2 
cases no mention is made in the histories as to the condition of the 


1. With few exceptions all pelvic inflammatory cases should be 
subjected to a course of preliminary treatment before operation is 
undertaken. If this is done, some will escape operation entirely, 
whereas others can be operated on more easily, more quickly, and with 
lower mortality;' and morbidity. A greater number of cases will also 
be found to be suitable for conservative operation. If possible, the 
patient's temperature and blood-counts should be normal for from foiu* 
to six weeks before operation. 

2. If pus is present and can easily be reached without traversing 
the peritoneal cavity, it should be evacuated at once. In a small 
percentage of cases the symptoms may be of such a character as to 
preclude the possibility of delay. Accurate diagnosis and a careful 
study of the cases will, however, show that but a small proportion 
require emergency surgery. 

3. The end-results of salpingostomies are, as a rule, disappointing. 
Pregnancy rarely takes place, as the newly formed ostia quickly become 
occluded and cause a recurrence of symptoms. 

4. Conservation of a grossly normal tube in the presence of dis- 
eased appendages on the opposite side offers good results, especially if 

' Diihrssen, M.: Trans. Amer. Gyn. Assoc, Philadelphia, 1906, vol. xxxi, p. 197 (dis- 
cussion of Dr. Man ton's paper). 

^ Giles, A. E.: Jour. Obst. and Gyn. of Brit. Emp., March and April, 1910. 


a course of preliminary treatment has been carried out prior to opera- 

5. Conservation of macroscopically diseased tubes is unsatisfac- 

6. Conservative ovarian surgery offers excellent results, provided 
that the ovarian circulation is not impaired and that the organ is left 
in a good position. This is strikingly exemplified in our series of 48 
double salpingectomies when one or both ovaries were spared, none of 
these cases requiring a second operation. 

7. In selected cases ovarian resection offers excellent results. If 
a small amount of ovarian tissue is left behind, this will usually avert 
the sudden onset of the menopause. The reason that many resected 
ovaries become cystic is because of the interference with the blood- 

8. When it is found necessary to remove both ovaries, a hysterec- 
tomy should nearly always be performed. Such uteri are useless and 
often give rise to subsequent trouble. 

9. If it is found necessary to remove the uterus and one or both 
ovaries can be spared, their preservation will prevent the unpleasant 
symptoms attending the artificial menopause; for although menstrua- 
tion will cease, the neuroses, which are the most distressing symptoms 
of the menopause, will be absent. 

10. A thorough curetage and iodinization of the uterine cavity 
should precede all abdominal sections for pelvic inflammatory disease. 
Areas of infection in the lower genital tract should subsequently re- 
ceive appropriate treatment. 

In order to obtain correct statistics regarding the after-residts in 
these cases a circular letter- was sent to each patient. In those cases 
that failed to reply a letter was sent to the patient's family physician. 
In these letters special inquiry was made as to the condition of the 
menstrual functi(jn, leukorrhea, dysmenorrhea, abdominal pain, preg- 
nancies, miscarriages, operations, or illnesses. Those patients who 
lived in the city or who did not feel entirely well were asked to return 
to the hospital for examination. A number of patients complied with 
this request, so that, in addition to the reply to our circular letter, many 
of our cases have been personally examined. No patient was classed 
as cured unless she or her physician considered that a cure had been 
effected, nor were any cases regarded as cured unless they were entirely 
free from pelvic .symptoms. Thus, if a patient complained of dys- 
menorrhea, she was classed as improved or unimproved, according to 
the severity of condition. As has been shown by the work of Marie 
Tol)ler,' from 50 to 7.') per cent, of all women suffer more or less at 

' Tdhl. 1. M.: Moimls. f. (id,, ii. flyn., l'.H)r>, vol. xxii, p. 1. 








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the menstrual periods, and it seems probable that some of the cases in 
the series under consideration that were classed as improved would 
actually compare very favorably with the average woman. No cases 
were included in this series that had been operated upon during the 
past year, whereas some of them are of eleven years' standing. One 
case of unilateral salpingo-oophorectomy was well for two j'ears, when 
a miscarriage occurred, and infection followed, requiring a secondary 
operation. This case was classed as unimproved, as was another case 
of unilateral salpingo-oophorectomy who was entirely well for thirteen 
months, when trouble recurred requiring a second operation. A case 
of bilateral salpingectomy and unilateral oophorectomy was well for 
two years, when, while lifting a heavy weight, the patient felt something 
"give way" in her abdomen and a uterine resulted; she was 
classed as unimproved. Following one of the ovarian resections the 
ovary became enlarged to the size of a lemon, and gave considerable 
trouble. Three months after operation, however, it was not palpable, 
and no symptoms were present. Seven years after the operation the 
patient was menstruating regularly and painlessh'. This case was 
classed as cured. In nearly all the oases dilatation and curetage were 
performed, together with a suspension operation; in some cases 
ventral suspension, in others, the Gilliam operation, and in the more 
recent cases, the Coffey operation, was done; ventral fixation was 
performed in some of the cases in which both tubes were excised. 


Indication. I'ndcr the heading Conservative Uterine Surgery 
it was stated that when it becomes necessary to remove both ovaries, 
a hysterectomy is indicated in nearly all cases. It is true that Web- 
ster' and Freund have utilized the uterus to cover a rent in the pelvic 
peritoneum or rectum after the ablation of both tubes and ovaries. 
Further autoplastic surgery has been reported by .Judct,' (^uenu,'' 
Sneguireff,' Summers,' Kelly," and others. 

Cases in which uterine autoplastic surgery are neces.sary are, how- 
ever, of extreme rarity, and carefully applied sutures usually answer 
the same purpose, and offer better hope of effecting a permanent symp- 
tomatic cure. As has previously been pointed out, uteri, if l(>ft in 

' Wclntcr. .1. ('.: (iynocoloKV and Aljiiominul SiirKcry, Kelly and NoMc, vol. i, p. (iJJ. 

^J^l<ll■t; La Rev. dc (lyn. ct do Cliir. Ahdoni., O Mili<r-. KlOd 

'Qui'mui: Trans. Krcncli .Surni'ons, Paris, ISiMI. 

' SncKuircfT, V. T.. Klin. Jour., Mo.scow, lOOl), \o. I, p 1 

'SinnnuTs: Surg., Gyn., and Obst., August, 1911. 

"Kelly, H. A., and Noble, C. P.: Gyneeology and .Vbdoniinal .'^urgery, (irsi cililion. 


place after the removal of both tubes and ovaries, not infrequently give 
rise to subsequent trouble. The indications for performing a hyster- 
ectomy and bilateral salpingo-oophorectomy have been extensively 
dealt with under the heading of Conservative Surgery of the Adnexa. 

Not a few cases will be observed in which, on account of the extent 
of the disease, no other form of treatment can be considered, and in 
these the choice of operation lies between a supravaginal hysterectomy 
and a total removal of the entire uterus and cervix. The supravaginal 
amputation is the operation most frequently employed. This opera- 
tion is more easily and quickly performed, and if the amputation is 
made at a low level, the cervix well cupped out, the canal widely 
dilated, the mucosa destroyed by the actual cautery, and the round 
Ugaments utilized for suspension purposes, equally good, if not better, 
results are obtained in the majority of cases than follow a panhysterec- 
tomy. It is imperative that all the mucosa of the cervical canal be 
destroyed. By retention of the cervix the anchorage of the uterosacral 
ligaments is retained, which materially aids in the suspension of the 
latter structure. 

Some surgeons prefer to remove the cervix in all cases. Schiff man and 
Patek^ state that their panhysterectomy cases have been more satis- 
factory than have been those in which the supravaginal operation has 
been performed. The surgeon should, however, be largely guided by 
the conditions present in the individual case. If cervical leukorrhea 
has been a pronounced symptom, and if this organ is heavy and greatly 
hypertrophied or presents an extensive laceration, and especially if a 
marked degree of eversion or cervicitis is present, a panhysterectomy 
is indicated. 

Several authors have reported the appearance of a bloody flow at 
irregular intervals following supravaginal amputation. But this may 
in most instances be ascribed to imperfect technic. To obviate this, 
Chaput,^ after the removal of the uterus and adnexa in the usual way, 
makes an incision into the anterior vaginal vault, slits the cervix, 
everts it, and excises the mucosa; he then sutures it in its original form, 
and invaginates it and closes the vagina above, de Rouville' recom- 
mends vigorous curetage of the cervical canal after supravaginal re- 
moval of the uterus. He scrapes out the canal with circular sweeps of a 
bistoury until only a thin shell a few millimeters tliick remains. The 
operation is then concluded in the ordinary manner. These pro- 
cedures have no advantages in ordinary cases over the operation 
already recommended. 

' Schiffman and Patek: Monats. f. Geb. u. Gyn., 1911, vol. xxxiii, p. .310. 

^Chaput: Rev. de Gyn., August, 1910. 

' de Rouville: Rev. Prat. d'Obstet. et de Gyn., Paris, October, 1912, vol. xx, No. 10. 


It would seem that the immediate mortahty of panh\'sterectomy 
should be slightly greater than in the less radical operation, as in the 
former the vagina is opened and the operation is more extensive. A 
study of statistics, however, fails to show any marked degree of dif- 
ference. As a means of lessening the dangers of post-operative in- 
fection in these cases de Rouville' recommends sterilization of the vagina 
with iodin. He reports 66 hysterectomies, of which 40 were sub-total 
and 26 total, with 2 deaths, neither of which was caused by infection. 

The question of cancer occurring subsequently in the cervical stump 
is worthy of consideration. If the cervical mucosa is destroyed by the 
cautery, this is extremely unlikely. Such cervices atrophy, and malig- 
nant changes are of extremely rare occurrence. Among 757 supra- 
vaginal hysterectomies performed for various causes in the Gyneco- 
logic Department of the University of Pennsylvania during the last 
twelve years, not a single known case of cervical cancer has occurred, 
although about half of the cases have been traced.- Giles^ asserts that 
the fate of the cervical stump after supravaginal hysterectomy need 
cause no apprehension. Of 181 of his cases not one showed any signs 
of malignancy, and in 98.3 per cent, no trouble of any kind was caused 
by the retention of the cervix. The immediate mortality in our series 
of 69 cases, in the majority of which supravaginal hysterectomies were 
performed, was 5.7 per cent. This includes death from all causes. 
One case died of post-operative peritonitis, one of volvulus, and two 
of heart and respiratory failure, in one of which the ether is believed to 
have been the contributing cause. Baldy^ states that in a series of 
223 cases of hysterectomy performed by himself and five other opera- 
tors, the mortalitj' was 2.68 per cent. It is not stated whether this 
represents the total number of deaths or is only the immediate opera- 
tive mortality. Davis^ reports a series of 22 cases in which hysterec- 
tomy and bilateral salpingo-oophorectomy were performed, in which 
the immediate mortality was 13.6 per cent. It should, however, be 
stated that many of these cases were complicated, all were drawn 
from free patients, and in all drainage was employed. A report from 
the von Herff clinic^ showed that of 45 drained cases, the mortality was 
24.4 per cent. These and other statistics indicate that hysterectomy 

' (If Houville: Bull, di; la Soc. d'Olistet. de Paris, February, 1911. 

'Since the above was written a case has occurred. Operation thirteen years prinr to 
the development of the; cancer. 

' (Jiles, A. Iv: Afler-rcsults of Abdominal Operations, 1910, p. hi. 

* Hiilciv: Killv and Noble, Gynecology and Abdominal Surgery, first edition, vol. i, 
p. C.'>I). 

' Davis, K. I'.: .-^mer. .Jour. Obst., September, 1911. 

" l{rp<,rl of the Sixth International Congress of f )l)sletrieians and Cyiiccolonists, Iler- 
lin. .September 9 to 13, 1912. 


carries with it a greater mortality than the less radical operation. Of 
the 321 cases of conservative operation previously referred to from the 
Gynecologic Clinic of the University Hospital, the mortality was 2.1 
per cent. This includes deaths from all causes. In a series of 2108 
conservative operations performed by various surgeons, the total 
mortality was only 1.3 per cent. 

Of 31 consecutive cases of hysterectomy and bilateral salpingo- 
oophorectomy for pelvic inflammatory disease, the after-histories of 
which could be traced, 24, or 77.4 per cent., are completely cured, 5 are 
improved, and 1 shows no improvement. This last case improved 
for about a year. Her symptoms were chiefly due to the artificial 
menopause. One year after the operation she had a stroke of apoplexy, 
and has been in ill health ever since. The chief symptoms from 
which the 4 improved cases suffered were constipation, and in 3, 
dyschesia. The pain in 2 of these cases was apparently due to ad- 
hesions. All these patients were of a constipated habit before opera- 
tion. Twelve of the 24 cured cases suffered from constipation before 
the operation, but are now normal. In none of the cases was there any 
pathologic leukorrhea following the operation. 

Giles' summarizes the results of 18 cases of total extirpation for 
inflammatory disease, and finds that a very marked improvement 
occurred in 17 of his cases, and also that in many of the women 
the sexual desire remained unaltered. In only 4 of the 18 cases, 
however, has the operation been performed more than two years 
before the report was issued. That the sexual appetite is not im- 
mediately lost after a panhysterectomy is well known. The excision 
of appendages the seat of inflammatory disease often removes the 
cause of a preexisting dyspareunia, and patients state that following the 
operation sexual desire is increased. The proportion of cases in which 
sexual desire is strong five years after the removal of both ovaries is 
extremely small. In 22 of the 31 cases of hysterectomy and bilateral 
salpingo-oophorectomy the after-histories of which we have been 
able to obtain, the vermiform appendix was removed at the time of the 
hysterectomy. Fifteen of the appendices were diseased. 

The same indication for drainage exists in cases of pelvic inflam- 
matory disease as exists in operations for other pelvic lesions. The 
old dictum of "when in doubt, drain," has been reversed, so that now 
we say, "when in doubt, do riot drain." The small proportion of cases 
that require drainage may be largely accounted for by the generally 

' Giles, A. E.: After-results of Abdominal Operations, 1910. p. 198. 



adopted system of not operating upon acute cases and by an improved 
operative technic. The use of the round-pointed needle and of cat- 
gut has practically done away with the employment of a gauze pack to 
control hemorrhage. At the University Hospital the inflammatory 
cases that are drained are those in which, for some reason, it has been 
found impossible to remove the entire abscess-sac, or when it has been 
necessary to leave behind a large amount of lymph. Drainage is also 
occasionally employed in those rare cases in which the small intestine, 
rectum, sigmoid flexure, urinary bladder, or ureter have been severely 
injured. Under such circumstances care must be observed to avoid too 
tight packing or placing the gauze too near the defective hollow viseus. 
If the drain is placed in direct apposition to the stitches, an intestinal 
fistula is likely to occur. The plan should be to have the drainage 
sufficiently near the suspected area to guide away any leakage that 
may occur, but not to come in immediate contact with the stitches. 
Such cases are very infrequent. In pelvic operations the operator has 
the choice of two routes of drainage — the abdominal and the vaginal. 
Unless contraindicated, the vaginal route offers many advantages. 

In 1897 Clark' stated that "if the pelvis is to be drained, the vag- 
inal route is preferable : the dangers of infection are no greater, and the 
dependent pockets in the pelvis can be drained much more effectively 
by this means." Olshausen' summarizes his opinion as follows: 
" In doubtful cases of deep-seated pelvic suppuration in women vaginal 
drainage is more reasonable than suprapubic." 

The material selected for drainage is usually sterile gauze, and in 
some cases combinations of gauze and soft rubber. For vaginal drain- 
age Bovee' employs a soft-rubber tube, one-half inch or more in diam- 
eter. The upper end of the tube had two lateral arms, each one inch 
in length, that overlap the uterosacral ligaments. These prevent the 
expulsion of the tube. Silk has been advocated by some authorities; 
the author has had no personal experience with this material. 
Among the last 100 cases operated upon for pelvic inflammatory 
disease in the (lynecologic Department of the University Hospital, 
drainage has been employed once. In all cases when the culdesac 
drainage is employed, the vaginal opening should be a free one. 
When gauze drainage is effected through the vagina, the custom 
at the University Hospital is to start the removal of it on the 
fifth day, and have the gauze entirely removed by the seventh daj'. 
liepacking is not neces.sary, and is, indeed, dangerous, because of the 

' Clark, J. {'■.: .\mor. Jour. Obst., 1897, vol. xxxv, p. (i.'id. 

■Olshausen: Zeit. f. (lob. u. Oyn., vol. xviii, No. 2. 

' HoviV, .1. W.: .Jour. Amcr. Med. .\ssoc., .luly 27, 1012. p. 2.->l. 


possibilities of infection and breaking up of adhesions. When tubal 
drainage is employed, vaginal irrigation may be given on the second or 
third day, but care must be taken that no force is used, the idea being 
only to wash away discharges; adhesions must not be broken up. To 
obtain a wide opening for drainage v. Toth^ advocates splitting through 
the entire length of the posterior cervical wall after performing an 
ordinary supravaginal hysterectomy. The incision is carried along the 
posterior vaginal wall for a greater or less distance, depending upon 
circumstances. Two sutures are introduced at each vaginal edge to 
arrest hemorrhage, and two sutures are placed on -each side of the 
cervix through the thickness of the wall. The outer parts of the broad 
Ugaments are closed in the usual way, and the anterior peritoneal flap 
is drawn across and united to the cervix along the isthmal aspect. If 
desired, the pelvis can be shut off from the drainage tract by bringing 
the sigmoid flexure across and suturing it to the anterior peritoneal 
flap. We see little advantage in thus splitting the cervix, and believe 
that a wide lateral incision through the culdesac is preferable. The 
utilization of flaps of peritoneum, or even the sigmoid flexure to wall 
off the drainage tract from the general peritoneal cavity is an excellent 
procedure, and has for years been utilized in certain cases in the 
Gynecologic Clinic at the University Hospital. 

The distressing symptoms accompanying the artificial menopause 
that so frequently follows the removal of both ovaries have previously 
been dwelt upon. That the ovaries elaborate an internal secretion, 
and that the removal of these organs is the cause of the artificial meno- 
pause, is now a well-established fact. By experimental work it has 
been determined that this secretion originates in the corpus luteum 
(Frankel- and many others). The ovarian secretion appears to act 
in conjunction with the secretion of other ductless glands. The re- 
moval of the corpora lutea in many cases produces general disturbances, 
such as proHf eration of the cells of the islands of Langerhans (Rebaudi^) , 
changes in the hypophysis (Giorgi''), disturbances of the thyroid 
(Rogers'"), and many other widely divergent results. CoUard and 
Huard* state that because of the close relationship existing between the 
ovary and the thyroid it is advantageous to combine these two extracts. 

' V. Toth: Zent. f. Gyn., 1912, No. 2. 

2 Fiankel, L.: Arch. f. Gyn., 1903, vol. Ixviii, p. 438. 

' Rebaudi: Zent. f. Gyn., 1908, No. 41. 

■* Giorgi : Ginecologia, 1906, vol. iii, p. 72.5. 

' Rogers, J.: Jour. Anier. Med. Assoc, 1912, vol. lix, No. 9, p. 702. 

Tollard and Huard: Thfee tie Paris (I'Obstetrique), 1912. 


That the disturbances produced by the removal of both ovaries 
vary widely in different individuals is also certain; some patients suffer 
but little, whereas in others general nervous manifestations are marked. 
It would seem that, upon theoretic grounds, the administration of 
corpus luteum extract to those patients who have been deprived of 
their ovaries as a result of surgical intervention during their active 
sexual life should be of great benefit. Frankel,^ in 1910, published the 
results of an extensive series of experiments on this subject. In 90 
per cent, of his cases the flushes and nervous symptoms of the artificial 
menopause were relieved. Burnam- has more recently reported 
equally good results. Mayo,^ Clark,^ Litzenberg,^ Mainzer,^ de 
Camboulas," Drevet,' Hill,^ and Godart'" have also reported' good 
results with this preparation in tliis class of cases. No serious ill 
effects follow the administration of corpus luteum extract by mouth, 
but Villemin," Ferroni,'- Lambert," and others have shown that when 
given intravenously toxic effects may be produced upon animals. 
Burnam'"' has employed finely chopped-up raw luteum of the sow fed 
as a salad or the dried products, and states that the latter is equally 
as effective provided it is freshly prepared. He states that patients 
vary widely in their susceptibility to the dried extract, and that the 
actual dose can be determined • only by experimentation. Some pa- 
tients complain of the taste of the tablets, and occasionally a slight 
gastric disturbance is produced. With these exceptions, Burnam'^ has 
noted no ill effects, even from enormous doses, while the beneficial 
results have been marked. In those patients who are relieved, the 
effect is generally noted in a few daj's. In some cases the administra- 
tion of corpus luteum extract appears to have no effect. The extract 
is an expensive preparation, and for this reason its long-continued ad- 
ministration is, in many patients, impracticable. The author's ex- 
perience with this preparation has been too limited to draw accurate 
conclusions from. Some cases appear to have been markedly benefited, 
while in other instances little or no result has been apparent. Whether 

' Frankol: Arcli. f. Gyii., 1910, vol. xci, p. 7.52. 

'Burnam, C. I"'.: Jour. .Vmer. Med. Assoc, .Vugust 31, 1912, p. (i9S. 

' Mayo, C: Jour. Amcr. Mod. .\hsoc., 1912, vol. lix, No. 9, p. 702. 

•Clark, S. M. D.: Ibid., p. 702. » Litzenberg, J. C: Ibid., p. 703. 

'■ Mainzpr: Di'ut. mod. Woch., 1890, No. 12, p. 188. 

' de Camboulas, B.: Le Sue Ovarien, Paris, 1898. « Drevct: Th&e de Paris, 1907. 

» Hill, C. A.: Surg., Gyn., and, 1910, vol. x, p. .W. 

i°G<xlart: Thfee de Paris, 1908. " Villemin: Thtse dt- Lyoii.s. 

" Ferroni, E.: .\nn. di o.stct. Milano, 1907, vol. i, p. 40."). 

"Lambert: Compt. rend. Soo. de Biol., 1907, vol. Ixii, p. 18. 

"Burnam, C. I'".: Jour. Anier. Med. .Vssoc, August 31, 1912, p. 098. 

"Burnam, C. 1'.: Loc. cil. 


in the latter cases the negative results have been due to improper 
dosage or faulty extract it is difficult to determine. The author has 
never seen ill effects follow its use, and believes that when given by 
mouth the preparation is practically harmless, although Krusen' 
states that in one instance he was compelled to reduce the dose because 
of cardiac palpitation following its use. The preparation employed 
should be a carefully made desiccated extract, and should be guarded 
against exposure to extreme heat or cold. Fluidextracts, whether 
aqueous or glycerinated, have not proved entirely satisfactory. 
From a study of the literature on this subject it would appear that the 
results have been sufficiently satisfactory to warrant the employment 
of this preparation in all cases exhibiting distressing symptoms of the 

artificial menopause. 

\nother therapeutic indication for lutein is in pregnant women, 
on whom operations upon the adnexa have been performed, and mis- 
carriage is feared. This is especially true during the early months of 
pregnancy, as the corpus luteum has been shown experimentally to 
have a definite physiologic action upon the fecundated ovum. As ■ 
a general rule, the extract should be given in gradually increasing 

As a safeguard against peritonitis, it is advisable to place all pa- 
tients in the Fowler position for the first twenty-four or forty-eight 
hours followihg operation, or even longer if distention or fever is 
present. A great advantage of the Fowler position is that if adhesions 
result, they occur in a position similar to that assumed by the patient 
while upon her feet, and are not, therefore, so prone to cause subse- 
quent distress. If the bed is well padded and adjusted to the pro- 
portions of the individual patient, the Fowler position does not 
usually cause inconvenience. If, after operation, areas of infection 
still persist in the lower genital tract, these should receive appropriate 
treatment. This is especially important in cases in which conservative 
operations have been performed. Failure in this detail and reinfec- 
tion from below doubtless account for a definite proportion of opera- 
tive failures. 

' Knisen, W.: Aracr. Jour. Obst., October, 1912, p. 524. 





In a previous chajiter the possibility of rupture of infiammatorj' 
tubal collections of fluid into the intestine, bladder, uterus, peritoneal 
cavity, or even through the abdominal wall was mentioned. Rupture 
or perforation of an adherent pyosalpinx into the rectum is not in- 
frequent, and into the bladder or upper intestine is more rare. 
Rupture into the peritoneal cavity seldom occurs, and is the form of 
accident described in the following pages. 

Rupture may occur spontaneously, or may be the result of direct 
violence, as from a kick or blow on the vulva, perineum, or lower ab- 
domen. Mann' and others report cases in which the injury is supposed 
to have occurred to patients during their transportation to a hospital 
for treatment for pelvic inflammatory disease. At least one reported 
case was caused by the trauma incident to a curetage, while Fisher- 
reports a case in which rupture was apparently caused by the apphca- 
tion of electricity to the lower abdomen. The Fallopian tubes, 
situated as they are in the pelvis, and surrounded laterally by the bony 
prominences, and protected from below by the strong perineum and 
the intervening structures, and from above by the thick layer of in- 
testines and the abdominal wall, make rupture resulting from acci- 
dental traumatism of rare occurrence. Rupture caused by ill-advised 
or too vigorous bimanual examination has occurred in a number of 
cases, as shown by the reports of Legueu' and Martin.^ Violent 
coitus may, in exceptional cases, result in the bursting of a pyosalpinx. 
Inflamed tubal collections may also rupture as a result of manipula- 
tions i)erf()rmed for the of inducing abortion, ("havassa"' 
recently reported a case of this kind, and Mary" has encountered three 

' Mann: Aiiicr. .(our. Obst., 1907, vol. Ivi, p. 461. 
•' Fi.shor, .1. M.: Triin-s. Phila. Obst. Soc, Juno 1, 1011. 

" Lctiiicu: Compt. rend. Soc. do (iyn. ot de I';cd. de Paris, 1903, vol. v, p. 83. 
' Martin: Rev. prat, d' ot do Pa^d. do Pari.s, 190G, vol. xix, p. 2.30. 
'- Chavassa, M.: Bull, ct do la Soc. Anat. do Pari.s, January .5, 1910, p. 79. 
" Marv, .\.: "Sur un ca.s do rupture de pyosalpinx pendant I'uocouoliemont," Th^o 
do Paris, 1908. 



similar cases in lying-in women. All died. Puerperal infection was 
the diagnosis made in these cases. Lejars' states that the flaring 
up of a previously chronic process may lead to rupture. Galliard and 
Chaput- have reported a case in which rupture occurred in a patient 
convalescing from typhoid fever. Latzko' and Cotte and Chalier* 
have each reported a case of ruptured abscess in an ovary. Lejars= has 
also encountered two cases in which the tube was perforated and had 
become gangrenous, the conditions resembling exactly those seen in a 
gangrenous appendix. The peritonitis following these cases was of an 
unusually severe type. In Brickner's^ case rupture occurred while 
the patient was straining at stool. A number of cases have been re- 
ported in which rupture occurred during pregnancy or labor. It 
is probable that if pelvic inflammatory disease did not usually cause 
sterility, rupture would be much more frequent, as the uterus slowly 
rising out of the pelvis, to which an inflammatory tube is densely 
adherent, causes traction on the tube, a drawing out and tliinning of 
this structure, which, if it does not itself finally cause rupture, produces 
in the tube a condition in which a small amount of trauma may pro- 
duce this lesion. Indeed, Gonsolin^ states that under such circum- 
stances tubes may even rupture as a result of traction in which both 
ends are patulous. Labor in itself may cause rupture. 

Spontaneous rupture is rare. Bonney,* in 1909, reported a case 
of rupture of a pyosalpinx, and carefully reviewed 44 other 
authentic cases collected from various sources. This writer' states 
that he wrote , to 50 surgeons, asking for reports of their experi- 
ence with cases of this character. Of the 40 who rephed, but 14 had 
seen the condition. Bovee,^" in 1910, collected statistics from 55 
cases, and submitted the history of an additional case wliich occurred 
in his own practice. In the majority of the reported cases there was no 
assignable cause for the rupture. In the minority of them such ex- 
citing causes as straining, lifting, the muscular efforts incident to 
labor, traumatism inflicted during coitus, and the use of violent purga- 
tives, seem to have been operative. In some cases rupture evidently 
follows a fresh puerperal infection superimposed on an old inflamma- 

' Lcjars, F.: Semaine M6dicale, Paris, April 12, 1911, p. 169. 
2 Galliard and Chaput: Semaine M^dicale, 1909, p. 538. 
5 Latzko: Geb. u. Gyn. Gesellschaft in Wien, March 17, 1908. 
' Cotte and Chalier: Rev. de Gyn. et de Chir. Abdom., 1907, vol. xi, p. 579. 
^ Lejars, F.: Semaine M^dieale, Paris, April 12, 1911, p. 169. 
' Brickner, W. M.: Surg., Gyn., and Obst., May, 1912, p. 475. 

'Gonsolin: These de Lyons; also quoted by Lamoreaux: Les Arch, de Gen. Chir., 
January, 1910. 

» Bonney, C. W.: Surg., Gyn., and Obst., 1909, vol. ix, p. 542. 

" Bonney, C. W.: Loc. cit. i" Bovee; Surg., Gyn., and Obst., 1910, vol. x, p. 405. 


tory process. Rupture usualh' takes place in the ampulla of the tube, 
although Alaryi reports a case in which the rent was found in the 
isthmus. In the cases of inflammatory disease of the uterine adnexa 
in wliich rupture occurs the primary condition is almost invariably a 
pyosalpinx. No rule can be formulated as to the size of the pyosalpinx 
in which rupture is most Ukely to occur — many of the reported cases 
have been small. Naturally those specimens in which the walls are 
thin and friable are more prone to this accident than are those in which 
the walls are thick and fibrous. Adhesions in some cases probably 
play an important part. Recent attacks of pelvic peritonitis, by 
augmenting the contents of the tube and thereby adding to the iiitra- 
tubal pressure, and by inflammatory changes in the tubal walls, 
increase to a great extent the likelihood of rupture. 

Symptoms. — The sj'mptoms arising from rupture of a pj'osalpinx 
or other inflammatory lesion of the adnexa naturally vary widely. 
If the rupture takes place into the peritoneal cavity, grave symptoms 
usually result. The severity of the symptoms depends largely upon 
the grade of the infection, and perhaps to a lesser degree upon the re- 
sistant powers of the individual patient. It is quite probable that 
when the tubal contents have become sterile, rupture of that structure, 
with escape of its contents into the peritoneal cavity, may occur, 
with little or no ill effects to the patient; indeed, the leakage from the 
end of a tube the seat of a salpingitis is but a mild form of an almost 
analogous condition. In 29 of the 31 cases analyzed by Bonney- in 
which rupture occurred into the peritoneal cavity, and in which an 
accurate history of the attack was procurable, the onset was abrupt 
and violent, and the evolution of the symptoms rapid. The fact that 
rupture is particularly Ukely to occur during an acute exacerbation 
when the infecting organisms in the inflammatory lesion are active, 
makes the prognosis in these cases much less favorable. Sudden sharp 
pain in the lower abdomen, at first most acute over the seat of the 
lesion, followed by more or less marked collapse and the rajiid develop- 
ment of diffuse peritonitis, constituted the symptom-complex. In 
Lamouroux's-' series the onset was sudden in every case, and was usually 
accompanied by violent pain over the .scat of rupture, which soon be- 
came general, involving the lower abdomen, and in many cases the 
entire peritoneal cavity. Nausea and vomiting frequently occurred. 
The temperature is often normal or subnormal for a few hours, and the 

' Mary, A.: "Sur un caa de rupture de pyosalpinx pendant raeeouelieinciit," Tli&^e de 
Pans, 1908. 

' Bonney, C. W. : Surg., Gyn., and Obst., 1909, vol. ix, p. 542. 
' Laniouroux, H. G. A.: Arch. G(5n. de Chir., Paris, September 2.5, 1912, p. 1005. 


pulse rapid and weak; pallor, sweating, and other symptoms sug- 
gestive of an internal hemorrhage are frequently early symptoms. 
The temperature soon rises, and other evidences of peritonitis rapidly 
become manifest. The disproportion between the pulse-rate and 
temperature in the very early stage is a suggestive sign. 

In those cases in which rupture of the tube has taken place during 
labor the symptoms have usually been attributed to ordinary puerperal 
infection. Fabricius'^ case is, however, an exception, and prompt 
operation resulted in the saving of the hfe of his patient. 

Diagnosis. — If the surgeon has made a pelvic examination of the 
case before rupture has taken place, and is, therefore, familiar with 
the size and shape of the diseased adnexa, a comparison between 
the collapsed tube and its former turgid condition will be of the 
greatest value in aiding him in arriving at a correct diagnosis. The 
condition must be differentiated from the acute exacerbation of a 
chronic pelvic inflammatory lesion; from torsion or rupture of an 
ovarian neoplasm; from torsion of an inflamed tube and ovarj^; 
from acute appendicitis with perforation ; and from ruptured ectopic 
pregnancy and other acute conditions of the lower abdomen that 
may cause peritonitis. From the first of these lesions rupture may 
be distinguished by the sharp, localized pain, the diffuse character 
of the infection, and by the severity of the symptoms. The cUnical 
picture presented by the rupture or acute torsion of an ovarian cyst 
is very similar to that of rupture of a pyosalpinx, but the absence 
of gonorrhea in the lower genital tract, the history of the case, and, 
lastly, the pelvic examination, should be sufficient to enable the 
surgeon to arrive at a correct diagnosis. Torsion of an inflamed 
uterine appendage is so rare a condition that it need hardly be 
taken into consideration in the ordinary case. In this condition, 
however, the symptoms are not always so acute; the picture of diffuse 
peritonitis is, as a rule, absent, or occurs somewhat later, and pelvic 
examination will reveal an enlarged, tense mass, whereas in the case of 
rupture, the cyst-sac is collapsed and reduced in size. The two condi- 
tions are, however, in some cases, indistinguishable. A number of 
recorded cases of spontaneous rupture of a pyosalpinx have been mis- 
taken for appendicitis or a ruptured tubal pregnancy, and the correct 
diagnosis has been made only after the abdomen has been opened. 
Lejars- strongly emphasizes the necessity for bearing in mind the 
possibility of rupture of an inflamed uterine adnexa when confronted 
with menacing peritonitis of unknown origin. The anamnesis of the 

' Fabricius: Wien. klin. Woch., 1897, vol. x, p. 10.56. 

2 Lejars, F.: Semaine M6dicaje, Paris, April 12, 1911, p. 169. 


case often shows acute flaring up of an infectious process just before a 
slight contusion occurs that induces the rupture. However, the his- 
tory of the case and a careful pelvic examination, if necessary, made 
under an anesthetic, should in most instances estabhsh the differential 
diagnosis between these two lesions. From ruptured tubal pregnancy 
torsion may be distinguished by the presence, in the latter, of evidences 
of pelvic inflammatory disease, the hyperpyrexia, the symptoms of 
peritonitis, and the absence, in many cases, of the signs indicative of 
internal hemorrhage. Fortunately, the treatment of all the conditions 
for which spontaneous rupture is likely to be mistaken is the same, 
viz., operation. In Bonney's' series of cases suflficient data were not 
obtainable positivelj^ to identify the variety of the infecting micro- 
organism in the majority of the cases. He states, however, that a large 
proportion of them were of gonorrheal origin. 

In a study of the literature of 91 cases, Brickner- found 11 to be 
clinically of gonorrheal origin. Many reports are entirely lacking on 
this point, but it seems probable that gonorrheal pus-tubes are quite as 
likely to rupture as are those due to other varieties of infection. The 
age of the patients varies quite widely, rupture naturally occurring most 
frequently at the period when active pelvic peritonitis is most frequent. 
Owing to the insufficient data supplied in many of the reports, nothing 
definite can be determined regarding the duration of the pyosalpinx 
and the number of acute attacks that have occurred prior to the rup- 
ture, although recent exacerbations undoubtedly exert a predisposing 
influence on this condition. 

Menge and others have established the fact that in a definite pro- 
portion of cases of gonorrheal pyosalpinges the tubal contents do not 
contain gonococci, or if these microorganisms are present, they possess 
only a limited degree of virulence. The severe symptoms that usually 
follow the rupture of an inflammatory tube is a strong argument in 
favor of the presence of a mixed infection in these cases. Another 
explanation is tliat the rupture fre(iuently occurs during an exacerba- 
tion of a preexisting pelvic inflammatorj' disease, a period when the 
microorganisms present in the tubal contents are likely to be especially 
virulent. During the ciuicsceiit ])eriod infiannnatory lesions of the 
tube are not enhirging, but during acute attacks more pus is frequently 
being formed within the tube, and, as a consequence, the intratubal 
tension is increa.sed and rupture at this period is, therefore, more 
likely to take place. Subsequent to the rupture gonococci have, in 
many cases, been demonstrated in the peritoneal exudate, but they 

' Bonney, C. W.: Surg., Gyn., and Obst., 1909, vol. ix, p. .542. 
' Brickner, \V. M.: tiurit., Gyn., iin<l Olwt., May, 1911', p. IT.'). 


are seldom found in pure culture, and are usually associated with 
other pathogenic organisms. Rupture probably occurs almost as fre- 
quently on one side as on the other, although Brickner' states that 
in 53 cases rupture occurred 33 times in the right tube and 23 times in 
the left. The fact that inflammatory tubal lesions are slightly more 
frequent on the right than on the left must be taken into consideration. 
The size and location of the rent also vary, but usually occur in the 
ampullae, and in some cases the rupture merely consists in the tearing 
open of the abdominal ostium, as in the cases recorded by Baisch,- both 
of which were of puerperal origin, while in others the rupture has been 
found in the tubal wall. As in many cases of pelvic peritonitis, the 
opposite tube is often diseased. 

Prognosis. — The prognosis is naturally dependent largely upon the 
variety and virulence of the infecting microorganism. Bonney^ states 
that of the 45 cases studied by him, recovery took place in 23 and death 
occurred in the remaining 22 — a mortality of 48.8 per cent.; while in 
Bovee's^ series of 56 cases there was a mortality of 58 per cent., 32 having 
died either with or without an operation. In Lamouroux's^ series of 27 
cases 9 patients succumbed. In 30 of Bonney's" cases it was possible 
to determine the time that elapsed between the rupture and the opera- 
tion. Of 20 patients operated upon during the first twelve hours, 14 
recovered and 6 died. One patient, operated upon at the end of twenty- 
four hours, recovered. Of 5 operated upon at the expiration of forty- 
eight hours, 4 died and 1 recovered. Of 4 patients operated upon be- 
tween the fourth and the tenth day, 3 recovered and 1 died. An 
analysis of the cases in which operation was refused or contraindicated 
by the gravity of the patient's condition shows that 1 patient died 
thirty-six hours after the presumable time of rupture; 1, forty-eight 
hours afterward; 1, seventy-two hours afterward; 2, ninety-six hours 
afterward; and 2 at the end of two weeks. Of the remaining 8 pa- 
tients, 3 of whom recovered and 5 of whom died, nothing could be 
learned either with reference to the time elapsing between the per- 
formance of the operation or the period intervening between the be- 
ginning of the attack and its fatal termination. All the 18 cases 
recorded by Bovee' which were not operated upon died. The length 
of time they survived after rupture varied from a few hours to three and 

' Brickner, W. M.: Surg., Gyn., and Obst., May, 1912, p. 475. 

2 Baisch: Miinch. med. Woch., September 19, 1911, vol. Iviii, p. 1994., 

3 Bonney, C. W. : Surg., Gyn., and Obst., 1909, vol. ix, p. 542. 

« Bov6e: Surg., Gyn., and Obst., 1910, vol. x, p. 405. 

' Lamouroux, H. G. A.: Arch. Gen. de Cliir., Paris, September 25, 1912, p. 1005. 

» Bonney, C. W.: Surg., Gyn., and Obst., 1909, vol. ix, p. 542. 

' Bov6e: Surg., Gyn., and Obst., 1910, vol. x, p. 405. 


one-half months. Two patients admitted to the hospital on the four- 
teenth day after rupture lived respectively four and twelve days. Of 
the 12 others that died without operation, and of which data were 
obtainable, the average number of hours that they survived was fifty- 
nine. Bovee^ and Bonnej'' reiterate the statement pre\iously made by 
Boldt' that there is not a single case on record in which recovery took 
place without operative intervention. In this connection, however, 
it should be remembered that the cases in which recovery would be 
likely to occur without operation, {. e., those in which the tubal con- 
tents were sterile or in which the microorganisms were attenuated, and 
in which, as a consequence, the symptoms would be of a milder grade, 
are the very ones in which a positive diagnosis of rupture would be 
extremely difficult to make. It, therefore, seems hkely that rupture 
ma}-, in some instances, take place and be mistaken for a simple 
exacerbation of an old pelvic lesion and not cause a fatal termination. 

Treatment. — .\11 cases of rupture in which the diagnosis is possible 
should be subjected to immediate operation. The type of operation 
indicated will naturally depend upon the extent and variety of the 
lesions encountered. 

The following is Bovee's^ tablg of cases of ruptured inflammatory 
adnexa, to which has been added a synopsis of additional cases that 
occurred since his excellent report was pubhshed, including two 
occurring in the Gynecologic Department of the University Hos- 
pital, neither of which has previously been reported. 

Martin^ reports briefly 2 cases of spontaneous rupture of a hydro- 
salpinx into the abdominal cavity, and 11 cases in which rupture 
occurred during bimanual examination. Huras^ reports 6 cases from 
Pozzi's chnic. A further contribution to the subject of rupture of 
suppurative adnexal lesions may be found in Lamouroux's paper in 
the These de Paris, 1912, which we have been unable to obtain at the 
time of going to press. 

' Bov(5c: Loc. cit. 

= Bonney, C. W.: Surg., Gyn., and Obst., 1909, vol. ix, p. 542. 

» Boldt: Amer. Jour. Obst., 1889, vol. xxii, p. 2fy2. 

* Bov(:'c: Surg., Gyn., and 1910, vol. x, p. 40.5. 

' Martin: Kev. prat, d'obst. ct do pindiat., Pari.s, 1906, vol. xix, p. 2IJ0. 

' Hura.s, H. : Mcnsuclles d'obst. ct do gyn., January, 1912. 

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This is a rare condition, and a search through the Hterature shows 
comparatively few recorded cases, when the frequency of inflammatory 
lesions of the adnexa is borne in mind. The reason for this can easily 
be understood when the anatomy of the tube and ovarj' is considered. 
The two requisites for torsion of these structures are freedom or laxity 
of adhesions of the tube or ovary, and a sufficiently long-drawn-out 
condition of the attachment of the organs so as to form a pedicle. 
Until the last few years torsion of the inflamed Fallopian tube has 
attracted but little attention in this country, although quite a few cases 
have been reported on the Continent, especially in France, where 
Hartmann and Reymond,^ Maillard,^ Cathehn,' and Simount'' have 
pubhshed monographs on this subject. In 1899 Praeger^ reported 
two cases, and was able to collect 20 others from the literature. Three 
years later Cathelin's^ work appeared, in which he reviewed the his- 
tories of 41 cases. The lines are not, however, sufficientlj- tightly 
drawn by Cathelin,^ who, for example, admits a case of parovarian 
cyst to his list. Hartmann and Reymond^ show the same laxity, as 
in their category they include a case of torsion of a normal Fallopian 
tube, and another in which an ovarian neoplasm was present. As 
torsion of ovarian and other new-growths of the adnexa is by no means 
unusual, these specimens should not be included under the heading 
of twists of inflamed uterine adnexa. Praeger' and Bell'" very properly 
exclude all such cases from their reports. Bell," in 1904, adds to Cathe- 
lin's'- list 13 new cases, including one of his own. It has been found im- 
possible, owing to the paucity of many of the reports, to analyze these 
cases from the bacteriologic standpoint. In the Laboratory of 
Gynecologic Pathology at the University of Pennsylvania one case 
of torsion occurred among 925 inflammatory tubal lesions, 147 of 
which were either hydrosalpinx or hematosalpinx. The history of this 

' Hartmann, H., and Reyinond, fi.: Annales de Gyn., 1898, vol. 1, p. 161. 

* Maillard: "De la torsion des salpingitis," Thfae de Paris, 1897-98. 

' Cathelin, V.: "De la torsion des hydrosalpinx," Rev. de Chir., Paris, 1901, vol. 
zxiii, p. 2o:i. 

* Simount, G. J. P.: "De la torsion du Pedicule dans Ics Salpingitis," Bordeaux, 1908, 
p. 50. 

' Praeger: Arch. f. G>ti., 1899, vol. Iviii, p. 583. 

•Cathclin: "De la torsion des hydrasalpinx," Rev. de Chir., Paris, 1901, vol. xxiii, 
p. 253. 

'Cathclin: Loc. cit. ' Hartmann and llcymond: Loc. cti. 

' Praeger: Arch. f. Gyn., 1899, vol. Iviii, p. 583. 

'» Bell, R. H.: Jour. Obst. and Gyn. of Brit. Emp., 1904, No. 5, p. 514. 

"Bell, R. H.: Ibid. 

"Cathelin: "Dela torsion des hydrosalpinx," Chir., Paris, 1901, vol. xxiii, 
P.2.W. i i • 


case has been fully recorded by Anspach/ together with a synopsis 
of 87 other cases collected from the literature. 

The exact etiology of torsion of inflamed uterine adnexa is difficult 
to determine, but is probably largely influenced by the same factors 
that are known so frequently to produce similar conditions in cases 
of ovarian neoplasms. Among the causative agents, therefore, are 
length of the pedicle, irregularity in the shape of the tumor, flaccidity 
of the abdominal walls, alternate filling and emptying of the bladder 
and rectum, peristaltic movements of the intestines, and rapid altera- 
tions in intra-abdominal pressure, such as are produced by pregnancy, 
labor, paracentesis abdominalis, alternate distention and evacuation of 
the intestines, sudden, unusual, or constrained movements of the body 
as a whole, such as stooping, turning the body to get out of bed, vomit- 
ing, trauma, falls or jolts, administration of an enema, gynecologic 
examinations, pressure of the abdomen against a hard object, as a 
wash-tub. etc. 

Bell- lays particular stress upon the action of the diaphragm in these 
cases. Payr^ has directed attention to another and what he believes 
to be an important factor in the production of torsion. This author 
believes that venous stasis in the pedicle, especially of small, freely 
movable tumors, may cause them to twist. The veins in many such 
pedicles are extremely tortuous, — much more so than the arteries, — 
and as a result of intense congestion, impart a spiral motion to the 
tumor; as twists occur the stasis becomes increased and a sort of 
vicious circle 'is formed. Payr's article contains a number of illus- 
trations. The ovarian veins are normally unusually tortuous, so that 
the foregoing theory is particularly applicable to torsion of inflam- 
matory tumors of the adnexa. Naturally, on account of adhesions 
and the shortness of the pedicle, twists occurring in appendages the 
seat of inflammatory disease are of rare occurrence. 

The ovary itself, owing to its situation and lack of pedicle, is rarely 
primarily subject to this condition, although not infrequently it par- 
ticipates more or less when the tube is twisted. Tubes the seat of 
pus collections seldom undergo torsion. A pyosalpinx is, as a rule, 
densely adherent throughout its entirety to the adjacent structures, 
and, owing to its generally smaller size compared to a hydrosalpinx, 
is much less likely to undergo twists than is a tube affected with the 
latter condition. In Anspach's* series of 88 cases of tubal torsion 

lAnspach, B. M.: Amer. Jour. Obst., October, 1912, p. 553. 
- Bell, R. H.: Jour. Obst. and Gyn. of Brit. Emp., 1904, No. 5, p. 514. 
2 Payr: Arch. f. klin. Chir., 1902, vol. Ixviii, p. 601; also Deut. Zeitschr. f. Chlrurg., 
1906, vol. Ixxxv, p. 392. 

■' Anspach: Trans. Amer. Gyn. Soc, 1912. 

Fio. 35. — Acute Pchulext Salpingitis. 
The tube is pipe shaped, and more closely resembles a serous than a purulent arcuinulatiun. Tlic inner half 
of the tube is but tittle enlarged, and the mesosalpinx is thin. The ampulla is dilated. The walls are thin, 
and the surface shows only a few slight adhesions. The abdominal ostium is contracted, and the fimbrice arc 
Btili to be seen. On section, the lumen was found to be necrotic and filled with pus. This is (he type of puru- 
lent tubal accumulation in which torsion may occur. 


there were 12 pyosalpinges, not all of which were, however, 
primaril}^ pus-tubes ; of these, 3 were known to be tubercular and 
3 more were possibly the result of this tj^je of infection. This is 
only what would be expected, as tuberculosis tends to produce a 
retort-shaped tubal enlargement more often than does the gonococcus 
or the other j^yogenic microorganisms. Also in tuberculosis the ad- 
hesions are often less marked than in the other forms of infection. 

In Cathelin's' list of 41 observations there were only 6 pyosalpinges, 
and he gives reasons for thinking that even these were not primarily 
cases of purulent salpingitis, but were, rather, originally hydrosalpinges 
wth subsequent intratubal suppuration. A hydrosalpinx, on the other 
hand, because of the frequent retort-like shape the tube assumes, 
which tends to elongate the isthmus of the tube and the mesosalpinx, 
and thus forms a pedicle, is much more prone to develop this complica- 
tion. The adhesions in hydrosalpinges are generally less numerous, 
and cases in which the ampulla of the tube is entirelj^ free are not 
unusual. Without exception, all the recorded cases that are accom- 
panied by a detailed description of the shape of the tube show that the 
chief enlargement is situated in the ampulla, and this is usually con- 
nected with the cornua of the uterus by a fairh^ long, gracile pedicle, 
consisting of the inner portion of the tube and the drawn-out and more 
or less thinned mesosalpinx. As previously pointed out, there can be 
no doubt that many of the cases reported as torsion of a pyosalpinx 
are in reality cases of hydrosalpinx in which pus or purulent material 
has formed as a result of the interference with the blood-supply caused 
by the twisting. The large proportion of cases of hydrohematosal- 
pinges and hematosali)inges can also be accounted for in the same 
manner, just as hemorrhage occurs in an ovarian cyst when its pedicle 
is twisted. 

Direction of Rotation. - The metliods of describing tlii.s condition 
are, as a rule, confusing. The best plan is that ad<jpte(l by the French 
writers, who state that the rotation is in the direction in which the 
hands of a watch travel, or is in the opposite direction. It is under- 
stood that the back of the watch is supposed to be toward the uterus 
and the face directed outward toward the tumor or the crest of the 
ilium. Cathelin^ gives the analysis of 12 cases in which it was jios- 
sible accurately to determine the direction of the torsion. 

' C'athclin: " Oc lii torsion tics liyilro.siilpiiix," Kev. dc Cliir., ]';iris, I'.IOl, vol. xxiii, ]). 

^Cnl)i(lin: '■ I)c la torsion (Ics hyilro>alpinx," Kcv. de Chir., I'liris, IttOl, vol. xxiii, 
p. 2.53. 


Right Side: 

In the direction of the hands of a watch 2 cases 

In the reverse direction of the hands of a watch 5 " 

Left Side: 

In the direction of the hands of a watch 2 cases 

In the reverse direction of the hands of a watch 3 " 

It can thus be seen that there appears to be no rule in this respect. 
The following table shows the ages at which torsion occurred in the 
46 cases in which it was possible to determine this point : 

1 case was under twenty years of age. 
16 cases were between twenty and thirty years of age. 
20 " " " tliirty and forty years of age. 

8 " " " forty and fifty years of age. 

1 case was between fifty and sixty years of age. 

Pregnancy does not seem to be a predisposing factor of much 
moment so far as torsion is concerned. Bell^ states that of 38 cases, 
10 were nulUparous, and 15 had only had one labor; while in Anspach's^ 
series 38 out of 65 cases in which the condition was noted had one or 
more children, a not unusual proportion. 

At the same time, several cases have been directly associated with 
pregnancy or the puerperium. Numerous pregnancies would naturally 
weaken the abdominal walls and thus favor torsion. On the other 
hand, inflammatory disease of the adnexa usuallj^ produces sterility, 
and unless the infection occurred as a result of childbirth, hydrosalpinx 
and other inflammatory tumors are generally absent during the puer- 

Torsion of the inflamed appendages, like a similar condition oc- 
curring in the pedicle of ovarian neoplasms, may be either of sudden 
onset, the twist interfering with the blood-supply of the tumor to such 
an extent that gangrene or other severe circulatory disturbances are 
produced, or the rotation may be slow and perhaps repeated a number 
of times, producing a more chronic lesion. No sharp line can be drawn 
between these two varieties, as various intervening degrees of torsion 
may be encountered. The acute type is the variety that has been 
most frequently recorded. 

In the cases recorded by Ries,^ Rouffart,"* Guicciardi,^ Kauff'mann,' 
and Kadigrobow,^ the torsion had been so complete as to produce an 

1 Bell, R. H.: Jour. Obst. and Gyn. of Brit. Emp., 1904, No. 5, p. 514. 
' Anspach: Trans. Amer. Gyn. Soc, 1912. 
» Ries: Amer. Gyn. and Obst. Jour., April, 1900, p. 325. 

' Rouffart: Jour. Med. de Bruxelles, 1900, No. 12, ref. Zent. f. Gvn., 1900, vol. xxxvii, 
p. 975. 

' Guicciardi, G.: Ginecologia, 1905, vol. ii, p. 110, 1 pi. 

» Kauffmann: Zent. f. Gyn., 1903, vol. -xlix, p. 139. 

' Kadigrobow, B, A.: Abst. Zent. f. Gyn., 1907, No. 32, p. 991. 


amputation of the tube, and in Waldo's^ case the tube was almost 
twisted off. Tubes the seat of the torsion usually present a dark 
reddish or blackish appearance, and show the same circulatory changes 
that are observed in ovarian neoplasms under similar circumstances. 
As before mentioned, the tubes that are the seat of torsion are usually 
of the retort-shaped variety, the outer end being enlarged, in the inner 
portion forming the more or less slender pedicle. As a result, the 
twists are almost always formed in the proximal half of the tube. 

Symptoms. — These naturally depend upon the aeuteness of the 
condition. A history pointing toward a previously existing pelvic 
inflammatory lesion can usually be elicited, whereas not infrequently 
prior attacks of torsion of a mild degree will have been present. In 
some cases the acute attack seems to have been produced by a sudden 
strain, as in Ross'- case, in which the twist was probably caused by the 
patient cranking a motor car. In other cases a fall, violent exertion, 
or straining at stool seems to have been the causative factor, while in 
still other instances the condition has occurred without assignable cause. 

In some cases the torsion is gradual and the onset of symptoms only 
moderately acute, while in others the torsion seems almost completely 
to shut off the blood-supph^ and as a result the symptoms are severe. 
In some cases it seems likelj' that a number of attacks caused by a 
gradual torsion have occurred. In 63 per cent, of the recorded cases 
the patients have been kept under observation for a time before opera- 
tion, showing that in a definite proportion the symptoms at the onset 
were not verj- alarming. ■Many of these cases were at first mistaken 
for an ordinary acute exacerbation of a pelvic inflammatory disease. 
In 17 of Cathehn's^ cases in which menstruation is mentioned, in 
only 4 was there any irregularity. The seizure is almost invariably 
ushered in by an attack of severe, sharp pain in the lower abdomen, 
over the seat of the lesion. This is accompanied by more or less 
marked symptoms of shock and collapse, which are followed shortly 
by the evidence of acute pelveoperitonitis, which not infrequently be- 
comes general. Nausea, vomiting, hyperpyrexia, and elevation of the 
pulse-rate are jirominent symj)toms. The aljdomen Ijecomes distended 
and tender, the recti muscles rigid, and constipation is the rule, and in 
some cases is absolute. Retention of urine or irritability of (he bladder 
and fre(iuency of micturition are often observed. Examination reveals 
the presence of a more or less fluctuating tumor, which seldom rises 

' Waldo: Amcr. .Jour. Obst., August, 1901, p. 17'.». 

' Uoss: Ainer. Jour. Obst., 1900, vol. liv, p. 033; also Trans. Amcr. Assoc. Obst. antl 
C.yn., 190G, New York, 1907. 

'Cathelin: "De la torsion des hydrosalpinx," Chir., Paris, I'.tOI, vol. xxiii, p. 


above the umbilicus and is of pelvic origin. This may be situated 
either in the pelvis or in the abdomen, but is usually low down. In 
cases in which a pelvic examination has been made prior to the attack, 
the change in the shape and consistence of the tumor will be a great 
aid in clearing up the diagnosis. Subsequent to the torsion the tube 
will be found to be somewhat enlarged, extremely tender, and often 
firmer than formerly, and to possess a rather more circumscribed range 
of mobility. The enlargement is sometimes very marked. Bimanual 
examination may show that the position of the uterus is altered. 
The presence of inflammatory disease of the opposite side is suggestive, 
as more than one-half of the recorded cases show this to be present. 
It may also be possible to demonstrate the pedicle of the tumor and 
its association with the uterus. These patients usually display such 
tenderness on examination, and the abdomen is often so markedly 
distended, that a general anesthetic is necessary before a satisfactory 
examination can be made. 

Diagnosis. — BelP and Anspach- state that an absolutely correct 
diagnosis of this condition has never been made. Torsion is somewhat 
more frequent on the right than on the left side. In the 88 cases 
analyzed by Anspach,^ 44 occurred on the right, 33 on the left, side, 
7 were bilateral, and the location of the remainder was not stated. 
The less space on the left side of the pelvis, owing to the presence of the 
sigmoid flexure, the more active peristalsis of the small intestines, 
and the cecum on the right, and perhaps the greater frequency of in- 
fection of the right tube, owing to the close anatomic relationship to 
the vermiform appendix, may perhaps account for this fact. As a 
result of torsion, rupture may occur, as in the cases of Lejars'* and 
Caput. ^ 

The symptoms and the abdominal and pelvic examination so closely 
simulate torsion of the pedicle of an ovarian tumor, and the latter 
condition is relatively so frequent, that torsion of inflamed appendages 
is usually mistaken for an ovarian neoplasm. Ovarian tumors are 
often round, and this point should be considered, as well as the fact 
that the latter are not, as a rule, associated with the other symptoms 
of pelvic inflammatory disease. Small ovarian tumors are the most 
difficult to differentiate. Torsion may also be mistaken for appendi- 
citis and intestinal, renal, or ureteral colic. These conditions should, 
however, readily be excluded if a careful study of the case and a 
thorough pelvic examination are made. Certain cases of ruptured 

' Bell, R. H.: Jour. Obst. and Gyn. of Brit. Emp., 1904, No. 5, p. 514. 
* Anspach: Trans. Amer. Gyn. Soc, 1912. ^Anspach: Trans. Amer. Gyn. Soc, 1912. 
' Lejars, F. : Compt. rend. Soc. d'obstet., de gynec. et de psediat. de Paris, 1909, vol. 
xi, p. 342; also Semaine m6d., Paris, 1910, vol. xxx, p. 325. 
' Caput: Rev. de Gyn., 1906, vol. x, p. 963. 


ectopic pregnancy may also closely simulate torsion, but the histoiy, 
the absence of other evidences of inflammatory disease, and the fact 
that in the latter the symptoms of hemorrhage are absent, should aid 
the operator in making his diagnosis. Torsion of gravid tubes has 
been recorded. Fortunately, the correct diagnosis is, as a rule, of 
no great practical importance, as operative intervention is required 
in all the conditions for which torsion is likely to be mistaken. 

In the 87 cases summarized by Anspach,^ 25 were diagnosed as 
ovarian cysts with twisted pedicle, in 20 as pelvic inflammatory 
disease, in 2 as gynatresia with distention, in 1 as acute strangulation 
of the intestine, and in 30 no clinical diagnosis was made. One 
remarkable case presented no subjective symptoms whatever, the 
tumor being discovered accidentally. 

Treatment. — Briefly summarized, it may be stated that inmiediate 
operation is required in all cases of torsion, and the earlier it is per- 
formed, the more favorable will be the prognosis. The type of opera- 
tion selected will naturally vary according to the nature and extent 
of the pathologic condition encountered. If the lesion is confined to 
one side, the opposite appendages being normal, a simple salpingo- 
oophorectomy, with excision of the intramural portion of the tube and 
retention of the uterus in a good po.sition, will usually be all that is 
necessar}\ On the other hand, if the lesions are extensive, a more 
radical operation will be rccjuired. 

The following is a summary of recorded cases, manj' of which 
have been taken from Anspach's- excellent paper on this subject. 
As has previously been mentioned, the etiology of many of these cases 
is in doubt. None, however, is included which is known to be caused 
by microorganisms other than the gonococcus. 

AWerlin (Lyon Med., 1011, vol. cxvii, p. 29). — Hydrosalpinx, twisted on uterine pedicle, 
ecchymotic in eolor and indicative of necrosis. 

AWerlin fLyon M^-tl., 190.5, vol. cv, p. 1040). — Case 1. — .Vkc, eiRhteen. Diagnosis before 
oper.ition: Bilateral ovarian cyst. Diagnosis after operation; Hilateral hydrosalpinx. 
Uiglit, twisted. Opposite side, hydrosalpinx and ovarian cyst. Repeated attacks of 
ovarian pain. 
Cage 2. -.\ge, sixteen. Hydrosalpinx. Twisted three times, with repeated attacks and 
abdominal pain becominK progressively worse. Diagnosis before operation: Ovarian with twisl('<l i)edicle. 

Amann (.Monal. f. Geb, u. Gyn., vol. xv. No. 2). — .Age, thirty-three. Il-para. Sudden 
attacks of .severe pain. Previous good health. Median abdominal tumor three inches 
below umbilicus. Operation ten days after attack. Diagnosis before operation: 
Ovarian cyst, torsion. Diagnosis at operation: Highl hydro.salpinx, twisted 2' ■• limes. 
Tube, 20 cm. long and (1 cm. in diameter. Number of adhesions to intestine and 

/lr//,iir rDeut. Zeit. f. Chir., vol. xlviii, Nos. 2 and .'?, p. 19S).— .\ge, twenty-one. Diagnosis 
before operation: Appendicitis or right adnexal Seven days before operation 

' .\nspach: Jjoc. cil. 

■• .\nspach. B. M.: Amer. .Jour. ( ) ,, October. 1912, vol. Ixvi, p. .'),■■):{. 


acute symptoms began. The tumor was present in the right iliac fossa, which was 
easily outlined. At operation hydrosalpinx was found in the right side, the size of an 
ostrich egg, the pedicle of which was twisted. 

Aulhorn (Zent. f. Gynak., 1910, No. 16, p. 538). — Age, nineteen. Three months pregnant. 
Pain for some weeks. Acute exacerbation two days before admission. Diagnosis 
before operation: Pregnancy and pyosalpinx. Diagnosis after operation: Right 
hematosalpinx, twisted 180 degrees; tumor 9 cm. long, dark-blue color; ovary in- 
volved; uterus gravid. 

Baldwin (Amer. Jour. Obst., 1906, vol. liv, p. 654). — Age, forty-three. No children; one 
miscarriage. In attempting to sit down, missed chair and fell heavily; three hours 
later, severe pain. Diagnosis before operation: Acute appendicitis. Emergency 
operation. Ovaries not disturbed and not affected. The tubes contained serum and 
blood. Diagnosis: Bilateral hydrosalpinx, right tube twisted and gangrenous. 

Baiidron (Compt. Rend. Soc. d'obst. de Gyn, et de Pied., 1900, vol. ii, p. 90). — Age, thirty- 
two. One miscarriage at nineteen years. Diagnosis before operation: Tubal preg- 
nancy (ruptured). Diagnosis after operation: Hydrosalpinx, twisted. Side, right. 
Size, orange. Location, tumor adherent to parietal peritoneum of pelvis. Form, 
irregular, nodular, ecchymotic. Pedicle, size of little finger. Torsion. 

Bell (Joiu-. Obst. and Gyn. of Brit. Emp., 1904, No. 5, p. 514). — Age, forty-five. Married 
at nineteen; child in eighteen months; no other pregnancies. Family history tu- 
berculous. Attack of severe pain in 1899, with faintness and vomiting; lasted two 
hours; no doctor. In 1901, another. Present attack sharpest. Abdominal tumor 
found. Diagnosis before operation: Ovarian cyst, twisted pedicle. Diagnosis: Hy- 
drosalpinx, twisted 1 ^/^, reversely to hands of watch. Twisted tube almost black in 
color. Left side also inflamed. 

Bland-Sutton (Surg. Dis. of the Ovary and Fallopian Tubes, London, 1891). — Case of 
Dr. H. Morris. Symptoms not acute; ovary not involved. A hydrosalpinx was 
twisted 3J-2 times. Numerous dense adhesions and partial amputation and parasitic 
growth resulting from impairment of the normal blood-supply. 

Boursier (Jour, de m^d. de Bordeaux, 1901, No. 30, p. 512). — Age, thirty-four. Nullipara. 
Diagnosis before operation: Endometritis; adherent retroflexion; salpingo-oophoritis 
(right). Diagnosis after operation : Right hydrosalpinx, twisted 2^2 tinies. Opposite 
side, follicular cysts in ovary, congested tube. In 1899 severe pains right iliac fossa, 
especially if fatigued, increased at menstrual periods; gradually grew worse, coming on 
in attacks when fatigued. During month before admission (1901) pains suddenly in- 
creased in violence \vithout apparent cause; went to bed; sUght fever and painful 
micturition. Objective signs: Abdomen not distended. Behind and to the right of 
uterus a mass not very hard, difficult to outline; tender. Operation: Right salpingo- 
oophorectomy. Result, cure. 

Brewis, N. T. (Edinburgh Med. Jour., 1910, N. S. 4, vol. i, p. 448). — Showed an example of 
torsion of the tube before the Edinburgh Obstetrical Society. There was no descrip- 
tion of any kind. 

Burrage (Bost. Med. and Surg. Jour., 1906, vol. chv. No. 11, p. 295). — Age, twenty-six. 
Married two years; nullipara. Treated for dysmenorrhea December, 1898. Dudley's 
operation. Pelvis negative, except prolapse of right ovary. Acute attack November, 
1899. Diagnosis before operation: Pelvic abscess. Diagnosis after operation: 
Hydrosalpinx twisted. Right salpingectomy; resection of both ovaries. Left tube 
normal. Both ovaries riddled with cysts. Twisted right hydrosalpinx adherent to 
bladder and surrounding structures. Color, dark, reddish-brown. Contents, blood- 
clot, no villi. 

Cathelin- {Rev. de Chirurg., 1901, vol. xxiii, p. 253).^Age, twenty-six. One miscarriage 
of five months seven years previously. Diagnosis before operation: Massive sal- 
pingitis (left); sUght adnexitis (right). Diagnosis after operation : Left hydrosalpinx, 
twisted 2J/2 times. Form, ovoid; color, blackish; contents, 200 grams blood; no 
clots; adhesions present. Ovary not twisted. Adnexa of opposite side normal. 
Objective signs: Tender mass in posterior culdesac (left). Subjective conditions: 
Very active pains in left lower abdomen three years before operation, without other 
symptoms; for three years uterine discomfort. Evening before operation, violent 
pains on rising from a chair. Operation: Unilateral salpingo-oophoreetomy. Result, 

Calhdin (Bull, et mem^ de la Soc. de Anat. de Paris, 1900, 6 S., T. ii, vol. Ixxv, p. 673).— Age, 
forty; Il-para. Sudden seizure; repetition in .sixteen days; mobile tumor on right, 


by pelvic examination. Left hydrosalpinx, twisted 1J4 times, direction of hands of 
watch. Ovary not involved. Blackish tumor. Right hydrosalpinx adherent in 
Douglas' pouch. 

Chido (Bull, et mem. de la Soc. de Anat. de Paris, 1900, 6 S., vol. ii, p. 41).— Age, tiiirty. 
XulHpara. Diagnosis before operation: Bilateral salpingitis. Acute exacerbation on 
right side. Objective signs: Abdomen distended on right side, rising nearly to umbiUcus. 
On left side, tumor size of mandarin orange, fluctuant. At operation: Right hydro- 
salpinx, twisted 3 times and contained 300 grams dark, bloody fluid and a small hemor- 
rhagic cyst of the ovary. Operation: Bilateral salpingo-oophoreetomy. Result, cured. 

Dclbel, P. (Bull, et mem. de la Soc. de Anat. de Paris, 1892, p. 300). — Age, thirty-nine. 
Diagnosis before operation: Intestinal strangulation from bands of volvulus of sigmoid. 
Operation within thirty-six hours. Diagnosis after operation: Left hydrosalpinx, 
3 twists. Right hydrosalpinx. Left ovary not twdsted. Objective signs: Palpation 
very painful. Suljjective conditions: Very sudden and severe pain; fainting. Patient 
fell while walking on street. Continued vomiting, not fecal. Pulse full, rapid; 
temperature, normal. Operation: Bilateral salpingo-oophoreetomy. Result, cure. 

Ddore and Alamartin (Lyon M6d., 1909, No. 9, p. 416). — Age, thirty-eight. No general 
history. No signs of inflammation. Diagnosis: Bilateral hydrosalpinx, right twisted 
2 or 3" times, containing one-half hter of fluid and shaped somewhat hke a bagpipe. 
Operation: Right salpingectomy. Left salpingo-oophoreetomy. Result of operation 
not stated. 

Fraenkel, L. (Monats. f. Geb. u. Gyn., vol. xxxv. No. 4, p. 459). — Age, twenty. Nullipara. 
Appendectomy five years before present attack. Fourteen days prior to operation 
severe pain in lower abdomen and vomiting. Diagnosis before operation: Bilateral 
ovarian cyst, torsion. Operation revealed right pyosalpinx the size of a man's fist 
and a twisted pedicle. Tube measured 20 cm. Left side similar, but no torsion. 
Bactcriologic examination. 

Francois (Societe Anatomique, October 30; La Presse medicale. No. 89). — Cystic salpingitis 
with torsion of pedicle. Abundant hemorrhage in tubal wall; hemorrhagic fluid in 
cyst cavity. Other tube normal. [No other data given.] 

Frilsck, H. (Die Krankheiten der Frau, Braunschweig, 1894, p. 469). — Simply declares that 
every hematosalpinx is not a tubal pregnancy and reports a very movable hematosal- 
pinx with a t«isted pedicle, but gives no deatils. Diagnosis: Hydrosalpinx, twisted, 
size of fist. 

Funke (Hegar's Beitrage, 1904, vol. vii. No. 3, p. 450). — Age, twenty-eight. Typhoid fever 
at twenty. Abdominal tumor for one-half year, increasing in size. Diagnosis before 
operation: Inflamed tumor of left adnexa. Diagnosis after operation: Hydrosal- 
pinx, twisted. Left side affected, well liidden by adhesions. Right also hydrosalpinx, 
not adherent, also twisted. Ovary, normal; left twisted 1^2 times opposite to direc- 
tion of th9 hands of a watch; right twisted 3^ with watch; clear yellow fluid. 

Cosset and Reymond (Ann. de Gyn., 1899, p. 21). — Age, thirtj'-one. Ill-para. Seat of 
tumor, left; size of fist. Pedicle twisted at 2 cm. from uterus. One twists in direction 
contrary to hands of watch. Contents, chocolate-colored fluid. No adhesions. 
Ovary twisted. Opposite adnexa healthy. Objective signs: Sui)rapubic rising 
to five fingers above [)Mliis; slight lateral inol)ilily; posterior culdc.sac filled l)y resistant corresponding with the siipi;ii)iiliic- tumor. Pain since first pregnancy, especially 
at periods, .\fter a long walk suddenly seized with severe pains in abdomen, most 
severe in left flank, radiating to lumbar region. Vomiting of food and bile. Operation. 
Result, cure. 

GouUioud (Quoted by Cathelin: Rev. de Chirurg., 1901, Xos. 2 and 3, p. 263).— Ago, 
thirty-seven. Nullipara. Diagnosis before operation: Pelvic myoma complicated by 
ovarian cyst. Diagnosis after operation: I''il)roma uteri and hydro.salpinx, twisted. 
Scat of tubal tumor, right, size of child's head. Two twists. Contents fluid, hemor- 
rhagic, not vi.scid. Ovary twisted. Opposite adnexa cystic. 01)jectivc signs: .\b- 
domcn distended; myoma reaching to umbilicus. In front of this hard tumor another, 
which is fluctuating, not reaching to symphysis. In right iliac fossa another smaller 
tumor, size of an egg, very hard and tender. For the eight days before admission to 
hospital acute pain with sud<len enlargement of abdomen. Pain radiating to right leg. 
Operation: Bilateral salpingo-oophoreetomy. Result, cure. Remarks: After opera- 
tion, retrogression of fibroma and improvement in pulmonary and pleural tuberculous 
lesions. The pelvic infection may have been tubercular. Not stated. 

Guicciardi, G. (Ginecologia, 1905, No. 4).— ,\ge, forly-nine. Single. Left tube and ovary 


and right ovary adherent. Right sactosalpinx, enlargement confined to ampulla. 
A number of twists occurred in the isthmus of the tube, and finally the tube became 
twisted off, lea\'ing a uterine stump 3 cm. in length. Guicciardi has seen 5 cases of 
tubal torsion in 10-41 laparotomies, with 3 actual amputations of the enlarged tube. 

Harpoth (Zent. f. Gyn., 1900, No. 52, p. 1399). — Age, twenty-six. No evidences of infec- 
tion mentioned. Operation six weeks after acute attack. Diagnosis before operation: 
Ovarian cyst and torsion; general health good. Diagnosis after operation: Bilateral 
hydi-osalpinx, left twisted 2J2 times. Although not definitely stated, presumably no 
tubal, but a few omental, adhesions. No bacteria found on microscopic examination 
and no cultures. 

Harlmaii, H., and Reymond,' E. (Annal. de gyn., September, 1894, vol. xlii, p. 172;. — Age, 
thirty. Subjective conditions: Pains in right side of abdomen. For last three years 
patient noticed tumor. Occasional severe attacks accompanied by vomiting. Right 
hydrosalpinx and cystic ovary. Adhesions to surrounding organs. Contents, IJ^ 
liters sanguinolent fluid. Diagnosis: Right hydrosalpinx, 2 twists in cUrection of 
hands of watch. 

Hartinan, H., and Reymond, E. (Annal. de gyn., 1898, vol. 1, p. 161). — NulUpara. Diagnosis 
before operation: Bilateral salpingitis I )i,ii;iKisis after operation: Bilateral hydro- 
salpinx, left tube being twisted in ilii i'rii(,ii ..pposite to hands of watch several times. 
This tumor is dark red, lobulated, aiid i.osxs.-cs a pedicle the size of a finger. It con- 
tained 400 grams bloody fluid. A number of adhesions were present on the right side. . 
The uterus itself was twisted }'^. Objective signs: Increase in .size of tumor, tender- 
ness, dulness, and symptoms of peritonitis, with v-iolent pains in right side radiating 
down thigh. Operation: Salpingo-oophorectomy. Cured. 

Harlman (Ann. de gynec. et d'obst., Paris, 1900, vol. liii, p. 119). — Case 1. — Age, forty- 
four. Pains in right side of abdomen, coming on in attacks for two years. Exam- 
ination: Subumbilical tumor; fluctuating. Right side. Pedicle size of umbilical 
cord. Twisted tv\ice. Color, brown. Contents, 500 grams blood. No mention of 
just what composed tumor — tube (?), ovary (?), both (?). No mention of opposite 
adnexa. Result, cure. 

Cose 2. — Age, twenty. When five to six months pregnant, suddenly seized with pain in 
right iliac region; vomiting; distention; fever. Operation next day. Right adnexa 
enlarged, adherent, hemorrhagic. Pedicle twisted once. Removal. Cure. Normal 
delivery at term. 

Case 3. — Age, tliirty-three. Curetage several times for metrorrhagia. December 7, 1899, 
sudden \iolent abdominal pains; in following days signs of pelvic peritonitis gradually 
subsiding. Tenderness remained. Large mass in abdomen,' reacliing to umbilicus. 
Operation January 3, 1900. Large blackish timior formed by right hydrosalpinx, 
with pedicle twisted directly. Ovary not involved. Uterus twisted J-^. Contents: 
Sterile fluid. 

Harlman, C. R. (Compt. rend, de la soc. d'obst. de gyn. psed., Paris, 1900, vol. p. ii, 254). — 
Age, twenty-five. I-para (eight months previous). Diagnosis before operation: 
Appendicitis or tubal disorder. Diagnosis after operation: Hydrosalpinx, twisted 
(right) J'2. Numerous adhesions. Ovary twisted. Opposite adnexa: Adhesions. 
Objective signs: Abdomen flaccid; tumor in hypogastrium, reaching to right iliac 
fossa; irregular; painful. Per vaginam, mass posterior to uterus, continuous with 
abdominal tumor. Six weeks previous to operation sudden abdominal pain without 
vomiting; fever. Operation: Unilateral salpingo-oophorectomy. Result, cure. 
Remarks: Appendix adherent; removed. 

Hedley, J. P. (Proc. Roy. Soc. Med., London, 1907-08, vol. i, p. 95). — Age, twenty-three. 
Single. Acute symptoms came on in a tram-car. Operation after seventeen days of 
acute pain in lower abdomen. Removal of aff'eeted tube. Diagnosis: Left hydro- 
salpinx twisted twice in direction of hands of watch; size of small orange. Contents: 
Sterile, thin, blood-streaked fluid. Ovary and appendix normal. No adhesions men- 
tioned. Recovery. 

Herjf, J). (Verhandl. d. Gesell. f. Gyn., Kong., 1895, p. 695).— Exhibited a specimen of 

torsion of a hydrohematosalpinx. [No details.] 
Hirst (Amer. Jour. Obst., vol. .\xxiii, p. 263). — Left side affected. Other pelvic organs 

normal. No other details. Diagnosis: Hydrosalpinx twisted 3 times, in association 

with myoma of uterus. 

Jacobs (Zent. f. Gyn., 1896, No. 50, p. 1283).— Ill-defined pain through lower abdomen, 
chiefly on the right side. At operation a myoma of the uterus was found and removed 
by vaginal morcellement. Right pyosalpinx and right ovarian abscess. Tube was 
twisted 3 cm. from the uterus. No gangrene was present. The tubal walls were thin. 


Kadigrohow, B. A. (Abst. Zent. f. Gj'n., 1907, No. 32, p. 991).— Age, twenty-six. Nulli- 
para. Right hydrosalpinx; slow twisting; almost complete amputation of tube. 
String-like connection, 1 cm. long. Contents of tube: bloody fluid. Tumor oblong, 
disseminated red spots. 

Kauffmann (Zent. f. Gynak., 1903, vol. .xlix, p. 139). — Age (?). lll-para; one miscarriage. 
Diagnosis before operation : Retroflexion with adhesion. Much pain; unable to work. 
Diffuse adhesions of both adnexa. Right side affected; consisted of two parts, a short 
uterine stump and an outer portion, 3 cm. long, with fimbriated extremity closed. 
Diagnosis after operation: Right hjdrosalpinx detached by torsion. 

Klein (Monats. f. Geb. u. Gyn., 1912, p. 655). — Age, thirty-five. Il-para. Diagnosis 
before operation: Ovarian cj'st; twisted pedicle. Three attacks of pelvic peritonitis 
pre\iously. Diagnosis after operation: Hydrosalpinx, twisted 360 degrees; ovary 
adherent; bluish-black tumor. 

Legueu and Chabry (Rev. de Gyn. et de Chir. abdom., 1S97, No. 1, p. 11). — This case appears 
to be the same as Case 1 in Presse medicale, 1900, p. 137. Alultipara. Sj-mptoms of 
pelvic inflammatory disease for some time prior to attack. Sudden onset of pain in 
ovarian region. Diagnosis before operation: Ovarian cyst with a twisted pedicle. 
Operation showed a large hj-drosalpinx twisted. Opposite adnexa normal. Recovery. 

Leyueu (Presse medicale, 1900, p. 37). — Case 1. — Age, thirty-three. Ill-para. Diagnosis 
before operation: Ovarian cyst with a pyosalpinx. Diagnosis after operation: Hydro- 
salpinx, twisted. Contents, 400 grams blood; ovary not twisted. Opposite adnexa 
healthy. Objective signs: Above and to right umbilical tumor with rounded upper 
margin, whose lower end reaches into small pelvis. On palpation, resistant, tender; 
hanlly to be felt per vaginam. Subjective conditions: Sudden pains at menstrual 
pcrind, especially in the right side; vomiting of food and bile. Operation: Unilateral 
.^alpingo-oophorectom}'. Result, cure. 
' 'ii.-ic 4. — Age, t wentj'-six. Diagnosis after operation : Right hydrosalpinx, size of hen's egg. 
Form smooth, regular. Twists, 1^2 times. No adhesions. Ovary not twisted. 
Objective signs: Mobile tumor, slightly tender, in posterior culdesac, independent of 
uterus. Subjective conditions; acute pains in abdomen at menstrual periods for past 
two years, especially right. Leukorrhea only during intervals. Operation: Unilateral 
salpingo-oophorcctomy. Result, cure. 

Lejars (La Gyn., January, 1910, p. 70; and Compt. rend, de la soc. d'obst., gyn., p;pd., 
Paris, 1909, vol. xi, p. 342). — Case 1. — Age, thirty-two. Diagnosis before operation: 
Fibroma (retroperitoneal). Subjective conditions: Three years previous, suddenly 
taken with pains in al)domen which lasted several days. Reappeared at menstrual 
periods and when fatigued. Three months before operation severe attack; bed for 
ten daj's. Objective findings: size of fist anterior and to left of uterus. At 
operation: Large, Ijlackish tumor anterior and left of uterus, everywhere adherent and 
corresponding to left adnexa, attaciied to left cornua by pedicle twisted twice, under- 
going ulceration. [Xo micnwcopic examination.) 

' -rvK 2. — Age, thirty-one. Ill-para. No pain until two weeks before operation; sudden 
onset. Objective Hndings: Cervix large, hard; in right culdesac ma.-ss size of two fists, 
hard, fixed. Operation: Mass consists of large tube twisted; loop of intestine adherent. 
< 'ontents, pus. 

i<c 3. — Age, thirty-eight. Nullipara; no miscarriages. Severe pains; sudden onset .six 
weeks before admission. IC.xaminalion: Nodular, hard tumor, fixed, reaching to three 
fingers below umbilicus, filling left iliac fo.ssa. Operation: Myoma with many in- 
testinal adhesions; left tube large, blackish, external half twisted, the torsion being 
maintained by fine, recent adhesions. Opposite adnexa normal. Operation: Hyster- 
ectomy and bilateral salpingo-oophorcctomy. Cure. 

Case 4. — Age, fifty. Ill-para. One miscarriage. For two months profuse metrorrhagia; 
leukorrhea. No severe pains; general feeling of weight in abdomen. Examination: 
Large adhircnl ina.-^s in pouch of Douglas, wiiich appeared to be in large part consti- 
tuted Ijy Miniflcxfd uterus. (Jperation: Uterus retroverted; on left, a prolap.sed, 
blackish tube lilled with hemorrhagic fluid, twisted several times on its peilicle. Ciire. 

Case 5. — Age, forty-three. Operated upon for uterine myoma. Hilateral hydrosalpinx 
size of lemons, each tube twisted on its pedicle. 

Case 0. — Age, forty. History and .symptoms of chronic salpingo-oophorilis. Operation: 
Right ovarv healthy; "the lube iii its inner three-<|Uarters, healthy; (he ampulla was 
transformed into a" little blackish pou<ii, attached to a twisted pedicle, and in part 
delacheil." Contents of the little ijoucli black, hemorrhagic li(iui<l, mixed with a 
little pus. Diagnosis: Salpingitis, torsion, necrosis. Tlio torsion and rupture had 
been eccentric and had involved only the ampulla. Opposite adnexa: Cystic ovary, 
tube large, closed. 


Case 7. — Age, twenty. Pains in right abdomen came on one month before operation. 
Painful micturition. Examination: Round tumor in suprapubic region (right), size 
of an orange; consistence of dermoid, which wa.s the clinical diagnosis. Operation: 
Large hydrosalpinx of left side, transposed to right, twisted 3 times on itself; 
torsion maintained by adhesions. Ovary healthy. Opposite adnexa normal; uterus, 
small. Result, cure. 
Lewers (Trans. London Obst. Soc, vol. xliv, p. 362). — Age, thirty-seven. Single. First 
attack of pain and vomiting December, 1901; second. May, 1902; third, September, 
1902. Diagnosis before operation: Bilateral ovarian tumor with twist of pedicle. 
Diagnosis after operation : Bilateral pyosalpinx, torsion on right side and adhesions to 
small intestine and bladder. Operation: October, 1902, bilateral salpingectomy. 
Diagnosis: Pyosalpinx twisted several times. Right ovary not involved. 

Maillard (These de Paris, 1893 and 1897, quoted by Legueu, Presse m6d., 1900, p. 37— 
second case). — Age, forty-nine. Ill-para; last, seventeen years previous. Diag- 
nosis before operation: Pyosalpinx, right, with less severe adnexal disease, left. 
Diagnosis after operation: Right hematosalpinx; twisted pedicle 13^2 times in direction 
of hands of watch. Form, globular. Ovary normal. Contents, coagulated blood. 
Opposite adnexa: Ovary cystic. Objective signs: Uterus three fingers above symphy- 
sis. Tumor felt high in right culdesac, size of egg, resistant. Attached to uterus on 
one side, to pelvic wall on other. In left culdesac a smaller, long tumor, attached to 
uterus, slightly tender. Subjective symptoms: Menstruated at age of tliirteen. Four 
years before operation leukorrhea, pain on urination, tenesmus; diagnosis of gonorrhea. 
Shortly afterward began to have abdominal pains, which for last year have considerably 
increased. These came on in attacks, always beginning on right side, radiating to 
lumbar region, and down tliigh to knee; vomiting; distention of abdomen; attacks 
lasted three days, gradually passing into period of calm, generally lasting about one 
and one-half months. In year preceding operation had had 7 attacks. Result, cure. 
Operation: Supravaginal hysterectomy, bilateral salpingo-oophorectomy. Remarks: 
Myoma of uterus present. 

Martin (Compt. rend, de la soc. d'obst., gyn., peed., Paris, 1906, vol. viii, p. 147). — • 
Age, thirty-four. Nullipara. Thought herself four months pregnant and threatened 
with miscarriage. Past four or five months distention of abdomen, accompanied with 
diminution in menstrual flow. Nausea and vomiting in morning. Just before ad- 
mission suddenly seized with violent abdominal pains; vomiting. Examination: 
Uterus normal in size. In right culdesac a rounded, fluctuating tumor, tender, distinct 
from uterus. Diagnosis before operation: Torsion of pedicle of small ovarian cyst, 
or probably a right salpingitis. Operation: Smooth, fluctuating tumor in pouch of 
Douglas with no adhesions, which proved to be a right hydrosalpinx; ovary not in- 
volved. Opposite adnexa normal. Tube measures 11x9 cm. 

Mclllroy (Scottish Med. and Surg. Jour., August, 1904, p. 150). — Age, forty-three. Mar- 
ried. V-para. Last labor eleven months ago. Attack of pain during last pregnancy, 
and felt as if there was some obstruction to last dehvery. Thereafter, pressure symp- 
toms. Left side affected. Diagnosis after operation: Hydrosalpinx; outer third of 
tube enormously distended; 3 twists of tube at different parts in direction of hands of 
watch; outer third necrotic. This, Mclllroy believed, was a parovarian cyst, but on 
studying the case more carefully believes it tubal. Complete torsion of tube at three 
distinct points; necrosis of outer cystic part, containing chocolate-colored fluid and 
flakes of fibrin. Parovarium distinct. Drawing resembles a parovarian cyst, but 
author regards it as a hydrosalpinx. 

Mclllroy, A. C. (Jour. Obst. and Gyn. Brit. Emp., 1910, vol. x\'iii, p. 368; also Proc. Roy. 
Med. Soc. London, 1910-11, Obst. and Gyn. Sec, p. 1121). — Age, forty-six. IV-para; 
last, twenty years ago. Severe pain in left ihac region, which came on suddenly five 
days ago. Chills and some symptoms of collapse. Menstruation irregular. Exam- 
ination: Mass as large as orange. Diagnosis: Myoma of uterus or tubo-ovarian tu- 
mor. Operation : Uterus enlarged and mass size of orange adherent to posterior uterine 
wall, which proved to be a left hematosalpinx. Two twists in uterine end. Ovary 
not involved. Recovery. 

Michel (Ann. de Gyn. et d'obst., 1907; ref. Zent. f. Gyn., 1909, vol. xxiv, p. 863).— Age, 
thirty-five. Married. Il-para. Operation: Four weeks after first attack. Both 
sides affected. No pus in tubes, although had fever. Diagnosis: Hydrosalpinx, right; 
twisted 4 times. Hematosalpinx, left; twisted 3 times. 

Montgomery, E. E. (Amer. Jour. Obst., 1912, vol. Ixvi, p. 272). — Age, twenty-two. Pre- 
sented symptoms suggestive of ectopic pregnancy. Operation showed a left pyo- 
salpinx, probably gonorrheal in origin, with torsion. 



Morel (Bull, et m6m. de la soc. anat. de Paris, December, 1903, p. 863). — Age, thirty-two. 
IV-para. Diagnosis before operation: Ectopic pregnancy. Subjective conilltions: 
Had missed no period. Severe pain on left side, spreading to entire abdomen. Vomit- 
ing bile. Examination of abdomen: Rigid, tender. Mobile, tender tumor in posterior 
culdesac. Operation (next day) : Uterus large, appears gravid. Right adnexa normal. 
Posterior culdesac occupied by a mobile, \iolet-colored tumor, developed from left 
adnexa, size of turkey-egg. Pedicle twisted 5 or 6 times. Wall of tubal sac delicate, 
and the hemorrhagic contents can be seen through it. [No anatomic diagnosis; ectopic 
(?); hematosalpinx?] 

Nanu (Bull, et mf-m. de la soc. de cliir. de Bucarest, 1900, p. 160). — Trans.: "M. Nanu 
presented a specimen, obtainetl by abdominal hysterectomy, of a uterine myoma ^\-ith 
both tubes. One of these, a right hematosalpinx, has the pedicle twisted" about its 
axis; it occupied the position of the cecum, which it resembles in form. It has also 
adhesions to the omentum." 

Orlner (Zent. f. Gyn., 1909, vol. xxix, p. 1025). — Age, thirty. Symptoms acute, followed 
straining at stool. Chills, vomiting, and pain. Operation after six days. Mass 
palpated a month before. Left tube thick as ball of thumb, swollen, and dark blue; 
mucosa necrotic. Tube twisted about 2 cm. from uterus, IK times in direction of 
watch. Right tube, abdominal ostium closed and contained pus. Omentum adherent 
to fundus. Left ovary normal. Hemorrhagic infarcts in tube wall; tube seat of tor- 
sion, and contained pus and blood. 

Pierson (Reported by Storer, Boston Med. and Surg. Jour., 1896, vol. cxxxv, Xo. 19, p. 461). 
— Diagnosis: Acute appendicitis. Right side affected. Pyosalpinx, which lay above 
pelvic brim, with fimbriated extremity looking toward the loin. Diagnosis: Pyosal- 
pinx twisted 1}'2 times, close to uterine end. 

Finard and Paquy (Compt. rend, de la soc. d'obst., gj'n., paed., Paris, October, 1901; ibid., 
1902). — The age in one reference is thirty-six and in the other twenty-six, but all other 
details are the same. I-para. Numerous severe attacks of pain during the second 
Ijregnancy and for past five years; vomiting in last attack; pain, nausea, frequent 
micturition, vomiting, diarrhea, meteorism, and icterus. Operation after induction 
of labor aiicl ein[)t ying of titerus because symptoms continued, especially fever. Right 
side affected. Right salpingo-oophorectoniy. Pregnant uterus. Diagnosis: Hyciro- 
salpinx twisted twice, reversely to hands of watch; size of orange. Ovary normal. 

Poirier el Calhelin (Bull. Soc. Anat. de Paris, 1900, p. 209). — Age, forty-two. Ill-para; 
last, twelve years previous. Diagnosis before operation: Retroflexcd uterus or prob- 
ably adnexal disease. Diagnosis after operation: Left, pear-shaped, nodular hydro- 
salpinx, size of orange. Twisted 3J4 times. Ovary also twisted. Objective signs: 
Resistant abdominopelvic tumor. Subjective conditions: Menstruated at twelve; 
irregular; active pains; metrorrhagia. Operation: Bilateral salpingo-oophorectomy. 
Result: Death next day. Remarks: Autopsy did not reveal cause of death. 

Polak, J. O. (Amer. Jour. Obst., 1912, vol. Ixvi, p. 272).— Age, nineteen. Acute onset of 
. symptoms. Operation three days later. The tube had been converted into a hema- 
tosalpinx and measured 10 x 8 cm. Torsion. The ovary was not involved. 

Pozzi (Compt. rend, de la soc. d'obst., gyn., pa!d.. Paris, 1900, p. 201). — Age, thirty-seven. 
Ill-para. In 1891 metritis following chilling during menstrual period. Extra- 
peritoneal evacuation of pus from left iliac region. Regained health. December, 
1899, fever, vomiting, pain midway between umbilicus and anterior supeiior spine. 
Tumor size of iiiunilarln at McHurney's point. Diagnosis before operation: .Appendi- 
citis. First operation, January 1, 1900: Right pyohematosalpinx size of orange, 
twisted once. Ojjposite adnexa not examined (right ovary also twisted). Conva- 
lescence normal until January 11th. T'ain left iliac region, beneath .scar of operation 
in 1891, fever. .Second operation January 14, 1900. Left iliac incision. Pus cavity 
adherent to scar. Pyosalpinx blackish in color, twisted once. Ovary carried down and 
forward; tube up and backward. Resembles adnexa of opposite side. Salpingo- 
oophorectomy. Result, cure. 

Pozzi (Compt. rend, de la soc. d'obst., gyn., pad, Paris, 1900, vol. ii, p. 95). — This is same as 
case in l{ev. de gyn. et chir. abd., April 10, 1900, p. 160. Age, thirty-three. I-para 
(forceps). Subjective conilltions: Metritis at age of twenty-eight, from time to time 
thereafter attacks of pain lasting two wi^eks at a time, not at menstrual periods. Janu- 
ary, 1900, very sever<' pains in lower abdomen. From then on several attacks of ab- 
dominal pain and constant bleeding until operation. Objective findings: Cervix 
large, .soft, patulous. Uterus large; to left and In front of uterus a cyst size of fetal 
head; on right, .slight Induration. Diagnosis before operation: Ovarian cyst, left; .sal- 
pingitis, right. Operation: April 2, 1900. Large tumor resembling ovarian cyst 


found on left side, but pedicle arises from right and proved to be an enormously dilated 
tube weighing 300 grams, twisted once reversely to hands of watch. Ovary sclero- 
cystic. Opposite adnexa: Ovary, normal; tube, hydrosalpinx. Bilateral salpin- 
gostomy. Result, cure. 
Praeger, J. (Arch. f. Gyn., 1899, vol. Iviii, p. 579). — Case 1. — Age, twenty-two. Nullipara. 
Suffered with delayed menses and distress in lower abdomen July, 1897. In October, 
1897, ovarian tumor cUagnosed; acute attack April, 1898, vomiting, constant and severe 
pain. Operation three months later. Diagnosis before operation: Adherent ovarian 
or tubal mass. Left ovary and tube removed; right ovary resected; right salpingot- 
omy. Diagnosis: Left hydrosalpinx twisted twice in direction of hands of watch. 
IDark-red color; hemorrhagic infiltration. Ovary involved. Numerous adhesions. 
Case 2. — Age, thirty-five. I-para. Nopainprior to February, 1899; thereafter, amenor- 
rhea for twelve weeks; severe pain; constant vomiting; retention of urine. Tumor 
in left abdomen found. Since then great tenderness over abdomen; tumor reaching 
to umbihcus on left. Chnical diagnosis: Left ovarian cyst with torsion. Operation, 
February 23d. Tumor measiu-es 10 x 10 x 7 cm. Diagnosis: Left hydrosalpinx, 
twisted twice in direction of hands of watch. Contents: Blood and bloody masses; 
hemorrhagic infiltration. Ovary not involved. Right side normal. 

Ries (Amer. Gyn. and Obst. Jour., April, 1900, p. 325). — Age, thirty-two. Married. One 
child eleven years ago; two miscarriages, one twelve and one eight years ago. Ailing 
since first labor. Attack of severe pain four years ago; in bed a week. Diagnosis 
before operation: Inflamed right adnexa. Right tube was found to have been con- 
verted into a hematosalpinx, size of egg, which has been spontaneously amputated by 
torsion. Numerous adhesions. Both ovaries removed because of peri-obphoritis. 

Rouffarl, E. (Bull. Soc. Gyn. and Obst., Brus.sels, 1900, tome x. No. 10, p. 257).— Age, forty. 
Il-para; last, eighteen months previous. Diagnosis: Retroversion of uterus. Left 
pyosalpinx size of orange, blackish in color. Ovary not twisted. Retroposition of 
uterus. Adhesions to rectum and lower portion of ileum. Right pyosalpinx 
adherent to rectum. Objective signs: Cervix patulous; retroversion. Tumor an- 
terior to left of uterus, fluctuating. Subjective conditions: Menstruation began at 
ten years; regular; recently paroxysmal pains on left side low down. Operation: 
Supravaginal hysterectomy and bilateral salpingo-oophorectomy. Result, cure. 

Rouffarl (Jour. med. de Bruxelles, 1900, No. 12; ref. Zent. f. Gyn., 1900, vol. xxxvii, p. 975). 
— Age, twenty-six. I-para. Complete separation outer part of right tube as a conse- 
quence of torsion, probably a previous hydrosalpinx; separated part adherent and 
parasitic; ovary adherent. Left parovarian cyst. 

Sampson, J. A. (Amer. Jour. Obst., August, 1912, p. 271). — Case in wliich the symptoms 
pointed to an acute pelvic condition on the right side. At operation the right tube 
was found to be the seat of the trouble, and was twisted and enlarged to probably 
twice its original size. Right salpingo-oophorectomy. The patient was nineteen years 
of age. 

Sanger (Zent. f. Gynak., 1893, No. 31, p. 727). — Age, thirty-nine. No children. For some 
time irregular menorrhagia and metrorrhagia. Acute pain in left adnexa. Operation 
after two months; no fever; vomiting. Bilateral salpingo-oophorectomy. Leftside 
affected. Right side inflamed; sm.-ill hyilidsalpinx. Diagnosis: Bilateral hydro- 
salpinx; Right tube size of an apiilr wiih luliiieral adhesions; hemorrhagic infarction 
from obstructed circulation. San{;cr attributed hematosalpinx and hemorrhagic 
necrosis in tliis case to the torsion. 

Siredy (Compt. rend, de la soc. d'obst., gyn., de paed., Paris, 1906, vol. viii, p. 150). — In 
discussing Martin's case, Siredy reports the following: Patient (age not given) had 
no symptoms whatever from genital tract. While at a watering-place, taken with 
enteritis; the local physician found by accident a timior the size of adult's fist in left 
side. Patient had no pain or symptoms whatever, but subsequently decided to be 
operated on. At operation a cystic hydrosalpinx with tliin walls, twisted twice, was 

Stark (Jour. Obst. and Gyn. Brit. Emp., 1911, vol. xix, p. 258). — Age, forty-six. Nulhpara. 
Attacks of pain for nine months. Clinical findings: "To right of uterus, tense firm 
body, size of ordinary tomato; on left side, marked enlargement of the tube. At 
operation, blood-clots in lower abdomen and a left hematosalpinx twisted 3 times. 
Ovary closely applied to tube. Right dermoid cyst, intraligamentous. 

Stolz (Monats. f. Geb. u. Gyn., 1899, vol. x. No. 2, p. 175).— Age, twenty-three. Single. 
Right side normal. Diagnosis: Left hydrosalpinx; diameter about 12 cm. and con- 
taining three-quarters liter of clotted blood and reddish-brown fluid. Twist, 540 de- 
grees; slow torsion. Operation: Left salpingo-oophorectomy. 


Storer (Boston Med. and Surg. Jour., 1906. vol. cliv, Xo. 11, p. 285). — Age, twenty-nine. 
Married si.x years. Xo pregnancies.' Xo l\istory of gonorrliea. For a j-ear dull pain 
in left side; recently pain before menstruation. Diagnosis before operation: Left 
salpingitis; right hydrosalpinx. Both tubes twisted; right side, no actual strangula- 
tion; left side, decided strangulation. Hemorrhagic infiltration and infarction on left 
side. X'^either ovary involved. Diagnosis: Hydrosalpinx ^bilateral;; right twist 
360 degrees, follows hands of watch; left hydrosalpinx twisted ISO degrees, direc- 
tion opposite to hands of watch. 

Slratz (Zent. f. Gynak., 1907, Xo. 31, p. 1444). — Age, thirty-six. Ill-para; last, twelve 
years ago. February, 1901), after moving, profuse bleeding and pain in right side. 
Operation: March 22d. Diagnosis before operation: Right tubal enlargement; 
hydrosalpinx, pyosalpinx, or tul)al pregnancy. Right side affected; left side, normal. 
Diagnosis : Hydrosalpinx twisted forward over round ligament and adherent to bladder. 
Contents partly pus. Microscopic diagnosis: Chronic salpingitis with torsion and 
formation of hematosalpinx. Bluish-red tumor. 

Taylor (Trans. Brit. Gyn. Soc, Jour. Obst. and Gyn. Brit. Emp., 1S93-94, vol. ix, p. 418).— 
Age, thirtj-. Married at nineteen; child at twenty. Had retroflexion and sterility 
for last seven years. Taylor did Alexander operation; the patient .shortly after be- 
came pregnant and was confined at term. Two or three months after had abdominal 
pain and tumor was found. Xo record of histologic examination. Possibly a cyst of 
tube, but he says presumably a hj'drosalpinx with twisted pedicle. 

Veil (V'erh. d. d. Ges. f. Gyn., 1S91, vol. iv, p. 216). — Age, twenty-seven. Three children. 
Suffered since last labor, two years previous. Sudden attack, severe pain in abdomen; 
seven weeks after first attack, another; four weeks later, a tumor, reaching to umbiUcus, 
was found. Diagnosis before operation: Torsion of ovarian cyst. Diagnosis after 
operation: Right hydrosalpinx twisted, filled with blood. 

Vernii (Th&se de Paris, 1911-12, vol. xlii). — Case 1. — Previously reported liy Martin. 
Case J. — Symptoms of pelvic peritonitis. Siidden onset of acute symptoms, with severe 

pain over affected area. Operation showed a twisted hydrosali)inx. Salpingo- 

oophorectomy. Recovery. 
Case 3. — Symptoms similar in general character to Case 2. Diagnosis after operation: 

Torsion of a hydrosalpinx. Salpingo-ociphorectomy. Recovery. 

Voiyl (Der Frauenarzt, 1909). — Age, sixty. Tumor noticed for some time; full feeling in 
abdomen; acute pain and tenderness. Diagnosis before operation: Large, uni- 
locular ovarian cyst, size of man's head, twisted pedicle. Diagnosis after operation: 
Left hydrosalpinx twisted 2}2 times and contained 4 liters yellow, straw-colored fluid; 
tumor has a dark-blue color from hemorrhagic infiltration. 

Walth (Amer. Jour. Obst., August, 1901, p. 179). — Case 1. — Age, .seventeen. .Vcute attack; 
previously good health. Operation two days after onset of attack. Diagnosis before 
operation: Acute appendicitis. Fever; rapid pulse; tumor in right iliac fossa; vomit- 
ing. Diagno.«is after operation: Right hydro.salpinx twisted 3 times; almost com- 
pletely aiiiputat<vl by strangulation; left side, normal; no ligature needed to control 
bleeding from pedicle, as amputation was almost completed by the torsion. 
Cage 2. — Age, twenty-six. Married fouryears; never pregnant. Well until three months 
previous. Since then, pain low down on left side. Fever; increased pulse; pain over 
entire lower abdomen, especially left. Abdominal tumor immovable, but slight 
fluctuation, reaching from symphysis nearly to umbilicus. Diagnosis before operation: 
Inllamed ovarian cyst. Operation two weeks after attack. Diagnosis: Ix-ft hydro- 
sali)inx infiltrated with blood, with .several distinct and complete twists. Kxtcnsive 
adhesions. No villi. Ovaries and left tube normal. 

Ward, F. N. (Amer. Jour. Obst., 1910, vol. Ixiii, p. 639).— Case /.- Age, 
Married twenty-one years. No children. \\\A\ until recently, except for sharp attack 
of pain in left ovarian region eight years liefore; occasional recurrence. Kxciting 
cause of this attack, cleaning and sweeping. Acute pain and symptoms of 
peritonitis. Diagnosis before operation: Ovarian cyst, twisted pedicle. Diagnosis 
after operation: Left hydrosalpinx twisted three times; left ovary involved; right 
hydro.salpinx; right ovary, normal. Free fluid blood in abdomen. 
<'(iHe 2.^\f[f, twenty-two. Marric(l four months; pregnant four months, .\ttack during 
pregnancy, characterized by nau.sea, vomiting, pain in lower right alxlonicn. Tempera- 
ture, 101° F.; pulse, 1 11).' Tender mass in right side of pelvi.s, beside the pregnant 
uterus. Presented the picture of diffuse peritonitis<l liy acute ap|)endii'ilis. 
Diagnosis after operation: liight hydro.salpinx twisted 4 times, gangreni;. UIooil- 
slaineil fluid present in the peritoneal cavity. Operation: Right salpingotomy, 
drainage. Recovery. 


Warnek (Rev. Aunal. de Gyn., 1894, No. 41, p. 335).— Cuse .2.— Age, thirty. Ill-para; 
first attack, six years ago; last, five months |)rcvimisly. Diagnosis before operation: 
Pyosalpinx. Diagnosis after operation: Ivislit hydrosalpinx size of potato, torsion. 
Contents: Outer two-thirds, dots; inner onr-tliinl, serous fluid; small abscess in wall 
of outer two-thirds. Opposite adnexa healthy. 
Case 3. — Age, forty. NuUipara. Diagnosis before operation: Bilateral ovarian cyst with 
twisted pedicle. Diagnosis after operation: Large right hydrosalpinx, somewhat 
Ividney shaped, twisted 43^2 times. Ovary not involved. Opposite adnexa: Tubo- 
ovarian cyst, intraligamentous. 

Weir (Araer. Jour. Obst., August, 1901. p. .520). — Age, forty-six. Married; two mis- 
carriages. Previously well. Aculi' :iii:Mk; severe pain in right lower abdomen; 
nausea; difficult micturition. Diati:iin>i,, Ij.lnrc operation: Ovarian cyst. Operation 
five days after. Right hydrosalpin.\ twisled twice. Dark red in color; hemorrhagic 
infiltration left side of tube and ovary adherent, otherwise ovary normal. 

WilUainsiin (Trans. Obst. Soc. London, 1905). — Age, eighteen. LTnmarried. Healthy 
until December, 1903; from that time to June, 1904, scanty and painful menses. 
.June 7th, severe pain in right side; later, diffuse pain, vomiting, and distention. 
Operation after two days. Right hydrosalpinx twisted 3 times, direction opposite to 
hands of watch. Contents: Blood; inner surface smooth. Ovary (right) congested, 
otherwise normal. 

Woolcomhc (Lancet, December 7, 1901, p. 1584). — Age, twenty-two. LTnmarried. First 
attack two years before in right lower abdomen. Repeated attacks since; last one 
week before admission. Abdominal tumor observed for two or three months. On 
right side abdominal tumor extends abov(^ the umbihcus; left side also, abdominal 
tumor rising out of pelvis. .Vilhisiinis \cry (■asily separated. Diagnosis: Pyosalpinx 
(l)ilatcrall ; right side with o\;iiy twisted 1 ' 2 times. Left side without ovary twisted 
twice. Right tube, circumference, 10 '2 inches; extreme length, 8 inches; dark bluish- 
red blood inside. Right ovary involved; measures 3x3 inches. Left tube, the bul- 
bous part, 7^2 inches long. Maximum circumference, 11 inches. Contents resemble 
cream cheese; no odor; no diplococci; no tubercles; no chorionic villi or signs of new- 

Further reference.s to torsion of inflammatory lesions of the ad- 
nexa, the original references to which have been unobtainable, may 
be found in the works of Cannone,' Fassano,'- and Pinard.^ 

The following are summaries of cases of torsion of the Fallopian 
tubes caused by non-gonococcal lesions : 

Anspaili. /)'. M. (.\iucr, Ji.ur. ( October, 1912, p. 553). — Age, twenty-six. Symptoms 
siiiiiilaiiiii; .nine a 1 1| leii. lull i> ( »| ii Ml revealed long, retort-shaped right tube con- 
taiiiiiii; lilnoil ami jius, twisled 2' 2 times in the direction of the hands of a watch. 
Salpiiinn-dniihiirectomy. Recovery. Subsequent to operation patient complained of 
pain in left ovarian region, and a few months later a second operation showed a similar 
shai)eil tube on the left side. Microscopic examination proved the latter to be tu- 
bercular in origin. The orifiiii of the infection on the right side was probably similar, 
but this point could not po^ilivejy be ileteniiined. because of the dense infiltration with 
blood and numerous heiuorrhagic infarcts which were present. Recovery. 

Awtray (Arch. Mens. d'Obst. et de Gyn., July, 1912). — A girl fourteen years of age pre- 
sented symptoms which were diagnosed as appendicitis; at operation the tube and 
ovary were found to be twisted tvnce in the direction of the hands of a clock. Salpingo- 
oophorectomy was performed and followed by recovery. The case is reported as one 
of spontaneous torsion of a normal tube and ovary. 

Chaput (Rev. de Gyn., 1906, tome x, p. 963).— Case ^.— Age, twenty. Never men- 
struated. At age of seventeen symptoms of gynatresia began. Objective symptoms: 
Abdomen swollen, resembling myoma. On percussion, clulness; on palpation, the 
uterus enlarged, hard, tender, reached to about umbilicus. Lateral mass which filled 

• Cannone: Anjou Med., Angers, 1911, vol. xviii, p. 1. 

°Fas,sano: Delia torsion pedunculo sacto.salpingi morgagni, Milan, 1909, vol. Ii, [)t. 
1, p. ;?73. 

= Pinard: Compt. rend. .soc. d'obstet., gyn., pa?d., Paris, October, 1910. 


pelvis and iliac fossa attached to uterus. Operation: Puncture of hymen, followed by 
discharge (IJ2 liters) of blackish blood. After puncture a large tumor could still be 
felt in the left iliac fossa. Laparotomy showed a large hematosalpinx on the right, 
twisted 6 times, and a small hematosalpinx on the left, twisted 5 times. Operation: 
Bilateral salpingo-oophorectomy. Death. 
Case 2. — Age, eighteen. Xo symptoms until sixteen, then symptoms of gynatresia com- 
menced. Objective findings: Tumor in right flank, rising to umbilicus. Operation: 
Vaginal section. Death. Autopsy showed hematometra. Right tube, hemato- 
salpinx, twisted once, including mesovarium. Opposite adnexa, similar pathology, 
but no twists. 
Lomlon Ohst. Soc. (London Obst. Soc. Trans., 1898, vol. xl, p. 325).— The president of the 
London Obstetrical Society, during the discussion of Bland-Sutton's paper on tubal 
pregnancy, stated that he had met a case in which the mole containing tube had 
become twisted on its axis, with results similar to those which occur when the pedicle 
of a small ovarian cyst becomes twisted. 

Marlin, A. (Zeit. f. Geb. u. Gyn., 1903, vol. xxvi, p. 221). — Age, thirty-one. V-para. 
Pain in lower left abdomen for two weeks, making patient unfit for work. Mass size 
of two fists in left side of pelvis. Right adnexa normal. Diagnosis: Left tubal preg- 
nancy, torsion and numerous adhesions, with bloody ascites. Clinical diagnosis con- 
firmed by microscope. 

McCann (Lancet, May 9, 1903). — Age, thirty-four. Curetage in 1898 for purulent dis- 
charge; no abnormality of adnexa at that time. Sudden seizure October, 1900. 
Similar attacks March, April, and May, 1901. Operation June 15, 1901. Right tube 
the seat of an ectopic pregnancy and twisted three times. Right ovary and opposite 
adnexa were normal. 

r. Mcrderrnorl, P. (Xederl. Tijdsch. voor verlosken Gyn., p. 175; abst. in Frommel's Jahres- 
bcricht, 1905, p. 209). — Age, twenty-four. Pain in lower abdomen for five years. 
At operation bilateral suppurative tubal lesions were found; the right side was twisted. 
Microscopically, these tubes proved to be of tubercular origin. 

Pozzi (Compt. rend, de la soc. d'obst., gyn"., pa^d., Paris, 1900, vol. ii, p.95). — Age, thirty- 
three. 1-para (forceps). Subjective conditions: Metritis at age of twenty-eight; 
from time to time thereafter attacks of pain lasting two weeks, not at menstrual periods. 
January, 1900, very severe pains in lower abdomen. From then on several attacks of 
abdominal pain and constant bleeding until time of operation. Objective findings: 
Corvi-\ large, sfift, patulous. I'terus large; to left and in front of uterus a cyst size 
of fetal head: on right, slight induration. Diagnosis before operation: Ovarian cyst, 
left: salpingitis, right. Operation: April 2, 1900. Large tumor resembling ovarian 
cyst found 1111 left side, but pedicle arises from right and proves to be an enormously 
dilated tul)e; weighs ',W() grains, twisted once reversely to hands of watch. Ovary 
sclerocystic. Contents of tube: Fetus, 3J^ cm.; dead, not macerated. Opposite 
adnexa: Ovary, normal; tube, hydrosalpinx. Salpingostomy. Result, cure. 

Ross (.\mer. Jour. Obst., 190(>, vol. liv, p. 0.53). — Diagnosis before operation: Acute ap- 
pendicitis. Pain began after cranking motor car. Emergency operation. Bilateral 
salpingectomy. Both tubes were the seat of suppurative tubercular lesions, and the 
right was twisted. 

Sampson, J. A. (Amer. Jour. Obst., August, 1912, p. 271). — Age, twenty-one. Sudden 
attack, simulating ovarian cyst, with torsion. Operation showed bilateral pus- 
tubes, with torsion on the right side. Supravaginal hysterectomy; bilateral sal- 
pingectomy. Highl oiipliorectomy. Microscopically, the tube proved to be the seat 
of a tubercular infection. 

Slrogaiiojf (Vratch, 1893, p. 1095, quoted from Praeger: Arch. f. Ciyn., 1899, vol. Iviii, 
p. 579). — Right hydrohematosalpinx and cystic ovary. Miero.scopic examination 
showed the tube to be the seat of an adenosarcoma twisted twice. 

Warriek (Rev. .\imal. de Gyn., 1894, Xo. 41, p. 335). — .Vge, forty-three. Ill-para. Diag- 
nosis before o|)eration: Right ovarian cyst, torsion. Diagno.sis after operation: 
Right tubo-ovarian cyst, twisted 1 ' 2 times; left hydrosalpinx, twisted 1)2 times. 
Microscopic examination .showed both tubes to be the seat of carcinoma. 

In 1880 Saiif^cr reported two eases of puerperal peritonitis that 
were probabl}- of gonorrheal origin. Between 1886 and 1891 Stevens, 


Loven,^ Penrose,- Huber,^ and Hatfield^ published cases in which 
they beheved the gonococcus to be the exciting cause. In 1891, at 
the meeting of the German Gynecological Society in Bonn, Wert- 
heim'' proved conclusively, as a result of carefully conducted ex- 
periments, that the gonococcus may, in some cases, produce a general 
peritonitis. Bumm had hitherto doubted the existence of this con- 
dition. Shortly after this Wertheim reported a case of general peri- 
tonitis in which the gonococci were recovered from the peritoneal 
exudate in pure culture. Owing to the rarity of diffuse gonorrheal 
peritonitis and the relative frequency of general infections of the peri- 
toneum resulting from other causes, no cases should be considered 
authentic unless they have been so proved by a careful bacteriologic 
examination. The work of Gushing,^ Hunner," Wertheim,* Goodman,' 
and others has amply demonstrated that the gonococcus may, in some 
instances, produce general peritonitis. That this is a rare condition is 
proved by the fact that in 1907 Goodman'" was able to collect only 75 
cases, and of these, only 30 had been confirmed by bacteriologic exami- 
nation at operation or autopsy. Diffuse gonorrheal peritonitis may 
occur in young girls before pubertj^, as a result of infection of the ex 
ternal genitalia or vagina, as shown by Comby" (8 cases), Northrup (2 
cases), Baginsky,^- Mejia,'' Galvagno,^^ Dowd,'^ Koplik,'^Variot,"and 
Cumston'* ; the youngest of these children was four years of age, and the 
oldest, twelve years. Comby's 8 cases all resulted from vulvovaginitis; 1 
was mild and X were severe. This author states that in children the 
onset of gonorrheal peritonitis is extremely sudden and acute. Rol- 
leston'' believes that mild cases are often overlooked or not recognized. 

1 Loven, G.: Hygeia, 1886. • Penrose: Med. News, July 5, 1890. 

= Huber, F.: Trans. Amer. Med. Soc., 1890, vol. vi. 
< Hatfield, M. P.: Arch. Pediat., 1886. 

' Wertheim: "Zur Frage von der Gonorrhoe," Verhandlungen der ileutschen Gesell- 
schaft f. Gyn., IV. Kongress, 1891, p. 346. 

« Gushing, H. W.: Johns Hopkins Hospital Bull., May, 1899, p. 75. 

' Hunner: Johns Hopkins Hosp. Bull., 1899, vol. xiii, p. 247. 

» Wertheim: Cent. f. Gyn., 1892, vol. xvd, p. 38.5. 

' Goodman, C.: Amer. Jour. Dermat., October, 1911. 

"> Goodman, C.: Annales Surg., 1907, vol. xlvi, No. 2, p. 111. 

" Comby, J.: Arch. mal. d. Enfants, 1901, vol. iv, p. 513. 

'^ Baginsky: Lehrb. der Kinderkrankheiten, 1902. 

"Mejia: Abst. Cent. f. allgem. Path. u. Path.-anat., 1901, vol. \a. 

" Galvagno, P. : Arch, di Pat. e clin. infant, 1903, vol. ii, Nos. 3 and 4, p. 73. 

'*Dowd: Annal. Surg., February, 1912. 

"■Koplik: Diseases of Infancy and Childhood, 3d ed., p. 571. 

" Variot: Gaz. des hopitaux, March 8, 1904. 

" Cumston, C. G.: Amer. Med. Jour., 1904, vol. iv. 

"RoUeston: Modern Medicine, Osier, vol. v, p. 531. 


White' thinks that one of the reasons for the rarity- of gonorrheal 
peritonitis is that the gonococci flourish best at a temperature of from 
91° to 98° F., and that a higher temperature, such as would be en- 
countered in the peritoneal cavity, inhibits its activity. 

TMien the normal resistance of the peritoneum is diminished, a gon- 
orrheal peritonitis is more likely to occur. The infection of the perito- 
neum not infreciuently follows a menstrual period and the puerperium. 
The disease is much more frequent in women than in men, because of 
the anatomic location of the organs usually affected by the gonococcus. 
Gonorrheal peritonitis may be produced bj^ the leakage of a pus-tube, by 
the torsion or rupture of an inflamed tube, or it may follow an opera- 
tion performed for pelvic inflammatory disease. In rare instances 
cases ha^-e been recorded in which the infection has been conveyed 
through the lym])hatic system. The anatomic lesions produced by 
gonorrheal peritonitis are usually slight as compared to other forms 
of infection in the peritoneal cavit}'. There is generally a uniform 
injection of the peritoneum, which is moderateh' dry. The peritoneal 
cavit}^, as a rule, contains but little pus. It is partly due to this 
viscid character of the exudate, which quicklj^ produces adhesion and 
thus tends to confine the disease to the pelvis, that general peritonitis 
of gonorrheal origin is so seldom encountered. 

Symptoms. — The sj-mptoms are those of general peritonitis, but 
they are usually moderately mild. They generally appear suddenly 
and are severe for the first day or two, after which time, in favorable 
cases, they gradually subside, the entire attack varying in duration 
from a few days to a week or more. Usually the physical evidences 
of peritonitis are most marked over the lower abdomen. The disease 
in more fatal in children than in adults. The mortality among the 
former has been estimated at 20 per cent, by Galvagno.- Among the 
30 cases of diffuse gonorrheal peritonitis collected by Goodman,^ and 
which were confirmed b\' bacteriologic examination, 14 deaths resulted. 
Twenty were operated upon, with a mortalitj' of 20 per cent. Two of 
these deaths cannot be ascribed to the operation nor to the gonorrheal 
peritonitis alone, as one case developed bronchopneumonia, and at 
autopsy, while gonococci were recovered from the peritoneal cavity, 
streptococci were found in the blood of the heart and other organs. 
The second case suffered from a severe empyema. If these 2 cases 
are excluded, the mortalitj' is reduced to 11 per cent, for the 18 cases 

' White: System of Medicine, .-Mlljutt mid Hollcston, lOO.'j, vol. i, p. S.i,"). 
' Galvagno: .-Vrch. di Patolog. e elin. infant, 1904, vol. ii, Xos. 3 and 4, p. 73. 
'Goodman, C.: Amer. .Surg., 1907, vol. xlvi, No. 2, ji. 111. 


subjected to operative intervention. Albrecht' reports 4 cases of 
gonorrheal peritonitis, all of which recovered. In 2, operation was 
performed. In each case the onset was sudden and moderately severe. 
Subsidence of symptoms occurred in less time than if the infection 
had been caused by the ordinary pyogenic organisms. This writer 
agrees with Doderlein that a good prognosis may be made in gonorrheal 

Grekow- records the histories of 2 remarkable cases of motor 
gastric insufficiency which he believes to have been of gonorrheal 
origin. Perigastritis, evidently the result of an old general gonorrheal 
peritonitis, was present, and resulted in spasm of the pylorus or 
hypertrophy and dilatation of the stomach. This observer states 
that the pylorus may become occluded by adhesions from without, 
or by a reflex spastic constriction. In either case the stomach shows 
evidences of great motor insufficiency, with hypertrophy of the pylorus 
and adhesions in its vicinity. Both the recorded cases occurred in 
females, one eighteen and the other twenty-two years of age. 

The following is the report of 2 hitherto unpublished cases of diffuse 
gonorrheal peritonitis occurring in the Gynecologic Department of 
the University of Pennsylvania Hospital: 

Case 1. — Colored woman, twenty-seven years of age. The patient 
gave a history of pelvic inflammatory disease of two months' duration. 
Pelvic examination revealed evidences of gonorrhea in the external 
genitalia and bilateral inflammatory adnexal lesions. At operation 
the peritoneal cavity was carefully walled off by gauze. During the 
course of a right salpingo-oophorectomy and left salpingectomy about 
a teaspoonful of pus was discharged from the right tube into the 
peritoneal cavity. Both appendages were densely adherent. On the 
third day following the operation the patient gradually developed 
symptoms of general peritonitis. The temperature never rose above 
102.2° F., or the pulse above 130. The abdomen was again opened, 
flushed with normal salt solution, and gauze drainage inserted. Cul- 
tures at this time showed the peritoneal exudate to contain gonococci 
in pure culture. But little free fluid was present. Convalescence 
was normal. 

Case 2. — White woman, thirty years of age. This patient gave a 
history of pain in the lower abdomen, dysmenorrhea, dyspareunia, 
and irregular and profuse menstruation. Exacerbations, during which 
the symptoms of pelvic peritonitis were present, had occurred a number 
of times. During the last of these attacks the symptoms became 
more severe, and evidences of general peritonitis developed, and on 
the second day of the attack the patient was admitted to the hospital. 

' Albrecht, H.: Munch, mod. Woch., October 1.5, 1912, p. 226.S. 

2 Grekow, I. I.: Zent. f. Chir., Leipzig, January 27, 1912, vol. x.wix, No. 4, p. 10.5. 


At this time the abdomen was distended and tender. Her temperature 
was 102° F. ; pulse, 126; respirations, 24. Nausea and vomiting 
were present. Evidences of gonorrhea were found in the external 
genitalia. At operation bilateral pus-tubes were found. The peri- 
toneum was reddened and the intestines were distended. Numerous 
light adhesions, especially in the lower abdomen, were observed. 
The appendix was normal. Bilateral salpingectomy and right oopho- 
rectomy were performed. Smears from various portions of the 
peritoneal cavity showed the presence of numerous diplococci, which 
corresponded in staining reaction and morphologj' to gonococci. 
Irrigation with normal salt solution. Gauze drainage. Recover}^ 

Diagnosis. — The diagnosis of peritonitis usually presents no great 
difficulty. On the other hand, positive proof that the gonococcus is 
the etiologic factor cannot be obtained without a bacteriologic ex- 
amination of the peritoneal exudate, which is, of course, impossible 
until the abdomen is opened. Under certain conditions, however, 
the gonorrheal origin should be strongly suspected. Summarized 
briefly, these are the presence of gonorrhea in the genital tract and 
the absence of other causative agents. The abrupt onset is also 
somewhat suggestive. (Jomby^ states, regarding children, that the 
onset of gonococcal peritonitis is absolutely "unforeseen and brutal." 
The degree of pain varies greatly in different cases. The symptoms 
are usually most marked in the lower abdomen. The temperature 
in adults usually denotes a somewhat milder grade of infection than 
is generally encountered in diffuse peritonitis of pyogenic origin. In 
neither of Cushing's- cases was the temperature above 100.5° F. In 
children the hyperpyrexia is often pronounced, the temperature not 
infrequently reaching 104° F. and the pulse 140 to 160. Brose,' 
Cashing,' and others have remarked upon the peculiar dry, fibrinous 
character of the peritonitis jiroduced by the gonococcus. In their 
cases there was j^ractically no free fluid in the peritoneal cavity. These 
jioints, combined with palpable tubal lesions, should lead to a correct 
diagnosis in the majority of instances. In children, the presence of a 
vulvovaginitis should lead to the consideration of this type of in- 
fection, and on account of the frequency of gonorrheal peritonitis in 
the young, the vagina should always be examined in cases iM'csenting 
symptoms of i^erilonitis. 

Treatment, 'i'lic approijriatc treatment will vary with liic in- 
dividual case. M the present time the general tendency, in all acute 

'Coml)y, ,1.: Anii. inal. d. Kiinmls, lOOl, vol. iv, p. .51:5. 
UJu-shing, H. W.: .Johns Iloplvins Mosp. Hull., Mi.y, ISW, p. 7.5. 
' Brosc, I'.: Hcrlln. kliii. Woclicnsclir., ISDli, vol. xxxili, p. 779. 
'CiLsliiiiK, H. W.: Johns Hopkins IIosp. Hull., May, IS'.m, p. 7.5. 


gonorrheal conditions, is to delay operative intervention, when this 
can be done with safety. The surgeon must, therefore, be guided 
entirely by the severity of the symptoms. One of the greatest dif- 
ficulties in these cases is to determine before operation the type of 
infection that is present. That a definite proportion of cases of difTuse 
gonorrheal peritonitis recover without operative interference has been 
amply proved. On the other hand, the dangers of non-operative 
treatment are many. Diffuse gonorrheal peritonitis has not in- 
frequently been mistaken for appendicitis, and the reverse is quite 
possible. Operative intervention in the series of 18 cases previously 
mentioned resulted in only 2 deaths — certainly not a high mor- 
tality. Without operation, many women become sterile and develop 
pelvic lesions that, if not subsequently relieved surgically, produce 
chronic invalidism. In a large proportion of cases the waiting policy 
merely means delay in operation. If the symptoms are such as to 
permit delay without danger to the patient, the subsequent operation 
can often be performed under much more favorable conditions, and 
with a mortality considerably below 11 per cent. If delay is decided 
upon, in the interval prior to operation the patient should be placed 
in the upright Fowler position, and physiologic normal salt solution 
introduced into the rectum by the Murphy enteroclysis method. 
At the same time the treatment appropriate for general peritonitis 
should be instituted. Koltz' calls attention to the vascular paralysis, 
especially in the splanchnic region, which is attendant upon general 
peritonitis, and' the heart failure which is secondary to this condition. 
The fall in blood-pressure and paralytic ileus and ischuria, which so 
frequently occur, Koltz- believes call for the exhibition of pituitrin. 
He reports 20 cases of general peritonitis treated with this preparation, 
with good results. 

Fvu'ther references to diffuse gonorrheal peritonitis may be found 
under the heading of Rupture and Torsion of Inflammatory Uterine 

According to Findley,'* probably the first recorded case of this 
condition was reported by Scanzoni,'' who described a postmortem 
specimen in which one tube was found distended with serum and the 
other collapsed. That true cases of intermittent hydrosalpinx are 
unusual is proved by Martin,* who found but 8 cases occurring in a 

' Koltz: Miinch. med. Woch., September 17, 1912. - Koltz: Loc. cil. 

3 Findley: Amer. Jour., 1906, vol. liii, p. 23(i. 

* Scanzoni: Krankh. d. weibl. Sexual-Organe, fourth ed., vol. ii, p. 7.5. 

5 Martin: Krankheiten der Eileiter. 


series of 1700 cases of salpingitis. The records of the Gynecologic 
Department of the University show but 3 cases occurring in a series of 
925 inflammatoiy tubes, 141 of which were cases of hydrosalpinx. 

Etiology. — Hydrops tubse profluens is due to a permanent closure 
of the outer and a temporary occlusion of the inner end of the tube. 
The latter may be caused by an inflammatory swelling of the mucosa 
or kinking of the tube. The secretions of the tube are thus retained 
until the inflammation of the proximal end of the ov^iduct subsides 
sufficientl}' to allow the escape of the fluid into the uterus, or until 
the intratubal tension is sufficient to overcome the obstruction, when 
the kink straightens out — much in the manner of the ordinary garden 
hose — and allows the tube to evacuate itself. The frequency with 
which the tube empties itself varies gi-eath' in different cases. Frank 
describes a case in which, for a period of six months, half a liter of 
fluid was discharged daily through the uterus. Our own cases also 
vary in this respect. In one case the condition had apparently been 
present for nearly two years, the escape of fluid occurring every four 
to eight weeks. In another case the tube evacuated itself much more 
frequentlj', although at irregular intervals. Bland-Sutton doubts the 
occurrence of this condition, believing that, in many of the cases, 
the fluid has its origin in the uterus. That the condition does, how- 
ever, occur has been amplyprovcd by the reports of Hennig,' Schramm,- 
Martin,'' Doran,^ and many others. Hydrops tuba? profluens should 
not be considered as a pathologic entity, but rather as a variety of 
hydrosalpinx. There seems to be no doubt that some of these cases 
may undergo a spontaneous cure and that in other instances the uterine 
end of the tube maj' be intermittently patulous for a time and then 
become permanently occluded. 

Symptoms. — These are similar to those seen in an ordinary case 
of hydrosali)inx, except that in this variety of lesion there is an inter- 
mittent discharge of fluid through the uterus, which is almost in- 
variably followed by temporary relief of symptoms. Bimanual ex- 
amination at this time will reveal the tube collapsed, while at a prior 
or later period a fluctuant, elastic tiuiior will l)e present. 

IntraiM-ritoncal goiiorrhoa shows a marked predilection for the 
pelvis, and only in rare instances does a general infection of the 
peritoneum result. A very unusual complication is that described by 

' Hennig: Tubenkrankh., Leipzig, 1870. 

'Schramm: .Arch. f. Gyn., voL xxxix, p. 17. 'Martin: Kranklinitpn cicr Eileifor. 

' Doran, A.: •Sy.stcin of Gynecology, vol. xxxix, |). 17. 


Brettauer/ who reports a case in which a gonorrheal infection took 
place in a large unilocular ovarian cyst. The nucroorganisms were 
recovered from the distal end of the Fallopian tube, from the uterine 
cavity, and from the contents of the cyst. Following removal of the 
cyst the patient made a normal recovery. Confrontation in this case 
proved that the patient's husband was suffering from an acute attack 
of urethritis. Repeated efforts, both before and after operation, to 
demonstrate the presence of the gonococcus failed to reveal the specific 
microorganism in the external genitalia of the wife, and while at 
operation the organisms were recovered from the Fallopian tube, 
macroscopically the latter organ was normal. Clinically, this case 
presented symptoms not unlike those produced by torsion. 


A mixed infection, i. e., gonococci and other organisms, such as 
the tubercle bacilli, is by no means uncommon. It is impossible, in 
many cases, to determine whether the gonorrheal condition is super- 
imposed upon the tuberculous or if the reverse is the case. Most 
authorities, however, believe that the latter is the more frequent condi- 
tion, and that once the tubal mucosa is altered by a gonorrheal inflam- 
mation an excellent soil for the development of the secondary infections 
is prepared. In the Pathologic Laboratory of the University of Penn- 
sylvania 31 cases of tuberculosis of the tubes have been examined by the 
author. In 20. of these the histories seemed to cover this point ; 6 of 
these have apparentlj^ been associated with clinical evidences of gonor- 
rhea. Owing to the fact that bacteriologic tests have not been performed 
upon the majority of these cases, it is impossible definitely to determine 
this point. The possibility of tuberculosis accompanying gonorrheal 
lesions of the adnexa should be weighed, and due precautions taken 
in making the prognosis and in instituting treatment in such cases. 

Cultures taken from cases of gonorrhea early in the acute stage 
usually show an unmixed infection, but when the disease becomes 
chronic and has been of long standing, mixed or, as Menge properly 
terms them, secondary infections, are frequently encountered. This 
point is of importance when employing the vaccine or serum treatment. 
Gonorrheal lesions of the adnexa often contain colon bacilli or other 
organisms. It seems probable that the gonococcus not infrequently 
prepares the soil for the streptococcus or other pyogenic organisms. 

' Brettauer: Amer. ,Jour. Obst,, 190S, vol. Ivii, p. 411. 



The fact that inflammation of the oviducts is often a forerunner 
of tubal pregnancy, and that salpingitis is one of the most freciuent 
causative agents in the production of tubal gestation, is now generally 
appreciated. Fehling^ reports the results obtained in 170 cases of 
early extra-uterine pregnancy, in nearly half of which, when a careful 
examination was possible, the opposite adnexa were found diseased. 
He also states that in 54 of 143 cases the lesions were so extensive as 
to make a bilateral salpingectomy necessarj-. This observer dwells 
strongly upon gonorrhea as a predisposing factor in the production of 
tubal pregnancy. 

Cones' states that an analysis of 202 cases of extra-uterine preg- 
nancy occurring in the Massachusetts General Hospital showed that 
over 88 per cent, of these cases were accompanied by inflammatory 
lesions of the tubes or ovaries. Meyer^ found that in a series of 44 
cases of tubal pregnancy more than 33 per cent, gave an antecedent 
history of gonorrhea. During the past twelve years 64 cases of tubal 
pregnancy have been operated upon in the Gynecologic Department 
of the University Hospital. Of these, 18 were in all probability as- 
sociated with or preceded by gonorrhea. Twenty additional cases 
presented pelvic lesions which, upon histologic examination, strongly 
suggested the presence of a gonorrheal infection. 

Primary carcinoma of the l'"alloi)ian tube is a rare disease. Until 
1909 only about 86 authentic cases of this condition were on record.^ 
Pathologists generally agree that inflammation is a predisposing factor 
to the production of carcinoma of the tube. The 4 cases which the 
author has had the oj)portunity of examining all showed positive 
evidence of preexisting inflammation. Rossinsky^ has recently re- 
ported in detail a case of primary carcinoma of the tube which he 
attributes to a previous gonoi-rhea. The tumor developed on the site 
of an old salpingitis. The relation which a preexisting endometritis 
may bear to the subsequent development of carcinoma is undetermined. 
Cullcn'"' states that he has (>xaniiiic(l llic mucosa in Id cases of car- 

' iM'hlini;;, II.: Arch. f. (lyii.. vol. xcii, .No. I, 

= Cones \V. P.: Ho.iloii Mcil. miil Surn. .lour., I!M I. vol. clxiv, p. ti77. 

' .Mcypr, F.: .Au.stnilian Mc<l. .lour., lM-l)ru:iry 17, I'.U'J. 

' Norris, C. C: Surg., Gyn., and Ohst., .\Iiircli, IDO'.l, p. 272. 

^ Uo.><sinsky, T. : Inaug. Dissert., Ha.scI, lillO. 

'•('iillcn, T. A.: CunriT of tlic rtcnis. KKH), p. H.VJ. 1 ). Applfton .V ( 'o.. N. V. 


cinoma of the body of the uterus, and found onlj' 2 in which there 
were any definite evidences of endometritis. He adds, however, 
that from the study of the material at his disposal he has not been 
able to arrive at any definite conclusion regarding this point. Theil- 
haber^ believes that chronic gonorrheal inflammation of large areas 
in the uterine mucosa and adnexa are predisposing factors to the de- 
velopment of carcinoma, causing interference with the nutrition of the 
parts, as well as by the direct irritant action of the discharges. 

The fact that a tube or ovary is the seat of an inflammation tends 
to prevent it from prolapsing into a hernial sac, the adhesions 
usually holding it in position. Cullen- has, however, recorded a case 
in which the left tube and ovary were removed for adnexitis. Later 
the patient developed an appendiceal abscess, which it was necessary 
to drain. A hernia developed in the appendectomy wound. At a sub- 
sequent date a tender mass could be palpated in the hernial sac. At 
operation this proved to be a hydrosalpinx and an adherent ovary. 
GoepeP has reported a case in which a pyosalpinx was found. From 
the description, however, it would appear that this specimen might 
quite readily have been a hydrosalpinx in which, as a result of inter- 
ference with the blood-supply incident to location within the hernial 
sac, suppuration had occurred. Le Nouene^ has also recorded the 
history of a casp in which a hernia contained both tubes and ovaries, 
the adnexa on the left side being the seat of a suppurative lesion. In 
none of the cases just described is the type of infection recorded. 


In 1903 Szasz^ reported the history of a remarkable case of 
elephantiasis of the external genitalia which was apparently secondary 
to or developed upon the site of a preexisting gonorrhea. A rectal 
stricture and gonorrheal proctitis were present. On microscopic 
examination the labia presented a typical picture of elephantiasis. 
The secondary characteristics were manifest in the enormously 
dilated lymph-vessels. Sections from the peripheral portions con- 
tained small cysts that could be seen with the naked eye. These 
contained clear lymph. The cysts were lined by a simple layer of 

' Theilhaber: Arch. f. Gyn., Berlin, 1912, vol, xcvi, No. 3. 
= Cullen: T. S.: Johns Hopkins Hosp. Bull., May, 1906, p. 152. 
' Goepel: Zentralbl. f. Chir., 1896, vol. x.\iii. 
' Le Nouene: Gaz. de Gyn., 190.3, vol. xv, p. 337. 

' Szasz: Monats. f. Geb. u. Gyn., 1903, p. 999. 

Fig. 30. — Carcinoma Which Occurred in the Fallopian Tube of a YorxG Woman. 
riie cureinoma has been implanted upon a preexisting inflammatory lesion. The cross-section of the tube 
shows the papillan,' character of the carcinoma. The left tube is the seat of a pyosalpinx. Both ovaries show 
cystic change and numerous adhesions. (For f\ill report of this case see Surgery, Gynecology, and Obstetrics, 
March. UtOy.) 


Fi<:. :i7. — C'aiu iM>MA OF THE Fai.loi'Ian Tvue (High and Low Tuwho. 
rti<- riiiihice .shows adhesiuns. Th<- inUHriihiriH ih ftomowhat thickened and HbrouH. and itt t«onie pointr* i.> 
infiltrated with groiipti of carcinomatous cell«. KvidcnccH of pret'xiHting inflnnunalion. characterlrcd by chronii 
inflnniMialory exufhitc and nunierou.** phicina-cellw. are everywhere prewnt. The high power Hhows the UNiia 
charnpterij.ii(> of carHnoma (Sure, flyn., and (iU^l.. March, IIHUH. 


endothelium. Stein and Heilmann^ record the history of a case of 
esthiomene of the external genitalia that seems to have been secondary 
to gonorrhea. Over both labia, but most marked on the right side, 
and about the anus were numerous macules, papules, and cysts, vary- 
ing in size from that of a pin-head to a kidney-bean. These were 
isolated or grouped, and those that were cystic contained a limpid 
alkahne fluid. Here and there superficial ulcerations were present. 
The condition was chronic, and the tumors were not sensitive. The 
patient had a rectal stricture. The authors st